Michael Bell, MD

Author: Michael Bell, MD,
Associate Director for Infection Control at CDC′s Division of Healthcare Quality Promotion.

CDC released a report today detailing two outbreaks that occurred when healthcare providers failed to follow basic injection safety elements of Standard Precautions.  These breaches resulted in life-threatening – yet completely preventable – infections in a number of patients receiving injections for pain relief.  How does this happen in today’s advanced medical settings?

In both outbreaks, healthcare providers were splitting single-dose/single-use medication vials meant for one patient into new doses for multiple patients.  There was a lack of awareness that this practice puts patients at risk of infection.  Because injections were prepared with new needles and syringes and, in one of the clinics, in a separate “clean” medication preparation room, providers thought they were being safe.  However, these preservative-free medications are not safe for multi-patient use.  Ultimately, ten patients in these two clinics required hospitalization for treatment of mediastinitis, bacterial meningitis, epidural abscess, septic arthritis, bursitis, and sepsis – all severe infections caused by either Staphylococcus aureus (Staph) or its drug-resistant form MRSA.

One & Only Campaign

Author – Joseph Perz, DrPH, MA
Prevention Team Leader for the Division of Healthcare Quality Promotion,
Centers for Disease Control and Prevention

You might be thinking, “Is a knowledge refresher on injection safety really needed?  Providers all know how to give safe injections!”  Sadly, this is not the case.  We at CDC have seen outbreak after outbreak related to providers not following safe injection practice standards as outlined in CDC guidelines.  We also see patient notifications that inform patients that they “may have been exposed – please be tested.”  Failures in basic patient protections that we see include the reuse of syringes or needles; the reuse of single-dose/single-use vials; and mishandling of multi-dose/multi-use vials.  With every outbreak or patient notification event that has occurred over the past 10 years, we have wondered how many other infections and exposures are slipping by, unnoticed. 

The CDC and the Safe Injection Practices Coalition have released a safe injection toolkit geared specifically for busy medical practices.  This free toolkit features a Power Point presentation with recorded audio, convenient for use during staff meetings, in-services, and other educational seminars.  Other pieces include a no-cost Medscape CME activity, a safe injection practices training video, and a number of eye-catching posters to remind staff about the basics of injection safety.