What’s New in the Patient Safety World
July 2014
Joint Commission Sentinel Event Alert:
Don’t Misuse Vials
We’ve done several columns in the past year about patients
being potentially exposed to blood-borne pathogens from misuse of insulin pens
in hospitals (see February 26, 2013
Patient Safety Tip of the Week “Insulin
Pen Re-Use Incidents: How Do You Monitor Alerts?” and our What’s New in the
Patient Safety World columns for April 2013 “More
Tips on Insulin Pen Safety” and April 2014 “Insulin
Pens - Again”).
But a far more common risk is exposing patients to infection
by misuse of single-use vials and even multi-dose vials. So much so that the
Joint Commission has just issued a sentinel event
alert on preventing infection from misuse of vials. The sentinel event
alert notes that vials intended for single use do not have preservatives so
they are especially prone to bacterial contamination and spread of infection.
Occurrences and outbreaks of blood-borne pathogens and
associated infections, including hepatitis B and C virus, meningitis, and
epidural abscesses. Adverse events caused by this misuse have occurred in both
inpatient and outpatient settings but 2 outpatient settings seem to be
especially vulnerable: pain management clinics and cancer clinics.
The biggest contributing factor is failure to adhere to safe
injection practices and aseptic techniques. Joint Commission cites statistics
that 6% of healthcare providers surveyed admitted using single-dose or
single-use vials on multiple patients and 15% using multiple-dose vials used
the same syringe to re-enter the vial numerous times for the same patient or
used the vial for multiple patients.
The sentinel event alert focuses heavily on CDC’s recommendations for injection
safety and CDC’s One &
Only Campaign. The latter emphasizes “ONE
needle, ONE syringe, ONLY ONE time”.
The alert goes on to provide recommendations for
standardized policies pertaining to single-dose/single-use, multi-dose, and all
vials. It also recommends doing audits
looking for open vials on various units. That’s an important recommendation. In
addition to formal audits, we’d recommend you add this to the activities you do on your Patient Safety Walk Rounds.
And the alert discusses the importance of training and education, safety
culture and reporting.
Call us skeptics. You can do all the education and training
in the world. But if you have vials and syringes in patient care areas it is
inevitable that someone will at some time misuse those vials. The fewer people
that have access to vials, the lower the likelihood that such misuse will
occur. Absent some changes in product design at the manufacturer/supplier
level, the best way to reduce the risk would be to have the pharmacy prepare
all such doses and provide them to the patient care areas in pre-filled
syringes. That solution might work in hospitals and hospital-based outpatient
clinics but is problematic in those office and clinic settings that do not have
access to a pharmacy.
We know that sometimes the misuse of vials is done with the
good intention of cost containment. There is no question that our suggestion
above or a change at the manufacturer/supplier level would increase supply
costs (and perhaps personnel costs). But you have to weigh that against the
costs (both financial and PR) you’d incur if you have to notify many patients
of potential exposure, do testing for pathogen exposure, and cover costs for
treatment of such exposure. In our April 2014 What’s
New in the Patient Safety World column “Insulin
Pens - Again” we noted that the cost of one full course of hepatitis
C treatment with the newer drugs just on the market is about $84,000.
This is a real problem. It deserves an industry-wide
solution. We only solved the unintentional lethal KCl
injection problem by taking vials of concentrated KCl
off patient care units. We similarly need to avoid enabling well-intentioned
healthcare workers from unintentionally exposing patients to infection through
misuse of vials.
References:
The Joint Commission. Sentinel Event Alert. Preventing
infection from the misuse of vials. Sentinel Event Alert 2014; 52: 1-6 June 16, 2014
http://www.jointcommission.org/assets/1/6/SEA_52.pdf
CDC. Injection Safety.
http://www.cdc.gov/injectionsafety/
CDC. One & Only Campaign.
http://www.oneandonlycampaign.org/
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