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Latest Sentinel Event Alert Targets Injection Safety

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By Megan Murdock Krischke, contributor

June 30, 2014 - The mishandling of injectable medical products can have extraordinary health consequences for patients as well as significant financial ramifications for the institution where the misuse occurred.  Nurses’ careers can also be impacted. Since 2001, there have been 49 reported outbreaks linked to the misuse of vials, and officials believe more go unreported.

Due to the serious consequences and the frequency of these events, The Joint Commission issued a Sentinel Event Alert on June 16, 2014, aimed at preventing infections from the misuse of vials and improving injection safety.

Pat Adamski: Speak up about injection safety.
Pat Adamski, RN, MS, MBA, FACHE, at The Joint Commission, urges nurses to speak up if they see another practitioner not following injection safety protocols.

“The concept of using ‘One needle and one syringe, one time’ is something you learn early in nursing school, but it is rarely revisited,” remarked Pat Adamski, RN, MS, MBA, FACHE, director of projects for the division of healthcare improvement at The Joint Commission.

“If you talk to any number of clinicians about their use of needles, syringes and vials, they all believe that they are well versed in the proper use of these items, but they often aren’t,” she continued. “They may need a refresher or they may be operating off of principles that went out of acceptance 20 or 30 years ago.”

The Centers for Disease Control’s (CDC’s) One and Only Campaign has a variety of resources for individuals and groups to sharpen their knowledge of vial use standards.

One common mistake that clinicians make is reusing the same needle and syringe on the same patient with both single-use and multiple-use vials.

“Single-use vials don’t have the preservatives multi-use vials do, so they are prone to bacterial contamination,” Adamski explained. “With the multi-use vials, injections are often made into an IV line, which may seem sterile, but, if connected to a patient, can still be contaminated with blood from that patient.”

“The CDC recommends that multi-use vials be used with just one patient,” she said. “While it is preferable to dedicate even a multi-use vial to just one patient, reality says that it often gets used for another patient and that is why it is important to always use a new syringe and vial for each administration.”

The misuse of vials is compounded by a desire to prevent waste and the shortages of certain medications.

“If a vial is contaminated with blood from a patient with Hepatitis B, Hepatitis C or even HIV, you could expose other patients to that.  And how do you track down which patients were exposed? It creates a huge nightmare trying to figure out who has been exposed and what they might need to be tested for. It is very difficult and costly for the organization and can create lifelong difficulties for the patient,” Adamski pointed out.

“All that follow-up, surveillance and treatment are much more expensive than that vial they were trying to save money on.”

Sara Linton-Beyer, PharmD., medication safety specialist at Loyola University Health System (LUHS) in Illinois, says Loyola is in the process of reviewing the alert to create a plan of action in response.

“We will be forming a multi-disciplinary committee to review current practice and will work with the patient safety evaluation committee to ensure our LUHS policy and procedures are in alignment with The Joint Commission Sentinel Event Alert,” she stated.

Paula Hindle: Injection safety requires properly cleaning vials.
Paula Hindle, RN, MSN, MBA, says one common mistake is not cleaning vial diaphragms properly.

“One of the big things we have gone to even before this alert is that we try to have every medication in a single dose so that a vial doesn’t have to be drawn out of multiple times,” added Paula Hindle, RN, MSN, MBA, vice president for nursing strategy and professional development at Loyola.

“What I see as being critical to this issue is creating a culture of safety within organizations,” noted Adamski. “We need to help practitioners to understand that if they see someone else not following the standards that they have an obligation to report that or to correct the behavior on the spot. Practitioners must feel that they can call each other on inappropriate or unsafe behaviors and practices. And that they can go up the chain of command if the practitioner is unresponsive to their intervention.”

The most important thing individual nurses can do to keep their patients safe is to know and follow the guidelines set out in the Sentinel Event Alert and to follow the protocols created by their organization.

“One thing I have discovered many practitioners don’t realize is that the diaphragm of the vial should be vigorously rubbed with alcohol for 15 seconds and then allowed to dry before each use,” stated Hindle.  “Practitioners should also be aware that after the first use of a vial it needs to be labeled with a ‘use by’ date, which is typically 28 days after the first use.”

“Nurses are the ones at the bedside with the patient and the ones most likely to see other practitioners breaking protocol. If nurses aren’t willing to speak up we won’t make headway on this issue,” urged Adamski. “Nurses need to be confident in their observation skills and confident that they are protecting the patient.”

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Top Safety Practices Impacting Patient Care 

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