Joint Commission Alerts Healthcare Industry to Prevalence of Unsafe Injection Practices


Patients visiting a clinic for an injection to relieve their pain or for chemotherapy don’t expect to leave with a new condition such as hepatitis, but unfortunately thousands of patients have been adversely affected in this way when they received an injection at their doctor’s office or in the hospital. Since 2001, at least 49 outbreaks have occurred due to the mishandling of injectable medical products, according to the Centers for Disease Control and Prevention (CDC). In spite of this, adverse events related to unsafe injection practices and lapses in infection control practices are underreported, and it remains a challenge to measure the true frequency of such occurrences.

To raise awareness of the issue, the Joint Commission today released a Sentinel Event Alert, “Preventing Infection from the Misuse of Vials.” The free publication was written to educate healthcare organizations and healthcare workers on the risks of misusing vials of injectable medical products. The alert describes the factors that contribute to the misuse of vials and recommends strategies for improvement.

The misuse of vials primarily involves the reuse of single-dose vials, which are intended to be used once for a single patient. Single-dose vials typically lack preservatives; therefore, using these vials more than once carries substantial risks for bacterial contamination, growth and infection. For multiple-dose vials, one survey of health care practitioners found that 15 percent reported using the same syringe to re-enter a vial numerous times for the same patient, and of that 15 percent, 6.5 percent reported saving vials for use on other patients. Patients exposed to these types of vial misuse have become infected with the hepatitis B or C viruses, meningitis, and other types of infections.

According to the CDC, adverse events caused by this misuse have occurred in both inpatient and outpatient settings. In outpatient settings, a high percentage occurred in pain management clinics where injections often are administered into the spine and other sterile spaces using preservative-free medications, and in cancer clinics, which typically provide chemotherapy or other infusion services to patients who may be immuno-compromised.

Much of the information and guidance provided in the Joint Commission’s periodic Sentinel Event Alerts is drawn from its Sentinel Event Database, one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in healthcare. The database includes detailed information about both adverse events and their underlying causes.  Previous Alerts have addressed risks associated with the use of opioids, healthcare worker fatigue, diagnostic imaging risks, violence in healthcare facilities, maternal deaths, health care technology, anticoagulants, wrong-site surgery, medication mix-ups, healthcare-associated infections and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission website at

Source: Joint Commission    


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