Sentinel Alert: Preventing Infection From the Misuse of Single-dose Vials

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Background information:
Misuse of single-dose medication vials are one of the causes of the transmission of recently reported avoidable bacterial infections. Single-dose vials do not contain preservatives and are susceptible to bacterial contamination. Using these vials more than one time increases the likelihood for bacterial contamination, growth and infection. The Centers for Disease Control and Prevention (CDC) report that misuse and adverse events have been reported in both inpatient and outpatient settings. Implication for the patient:

The CDC reported that patients are being exposed unnecessarily to bacteria that cause life-threatening infections. A significant contributing factor to the misuse of vials is the lack of adherence to safe infection control practices and to aseptic techniques within health care organizations. Less-than-optimal practices such as multiple use of a single-dose vial may contribute to life-long treatment and even death.

Recommendations from CDC and the Joint Commission:

  • Use the single-dose vial once.
  • Follow aseptic techniques.
  • Practice safe infection control practices as outlined by your healthcare organization.
  • Follow safe injection and infection control practices.
  • Discard the vial after a single use; used vials should never be placed back on drug carts.
  • NEVER combine leftover contents of single-dose vials.
  • NEVER store used single-dose/single-use vials for later use, no matter what the size of the vial.
  • Conduct regular quality checks on clinical units to look for open vials.
  • Discard any vial if its sterility has been compromised or is questionable- even if the vial is unopened and/or unused.
  • Provide annual education on injection safety and on preventing the misuse of vials for all staff who administer injections, including new and temporary staff.
  • Before discharge, provide injection safety education to patients and caregivers who will use injectable medical products as part of a home health regimen. Use teach-back methods to assure understanding.
  • Create a culture within which the reporting of unsafe injection and infection control practices or near misses is viewed as a necessary step to improve safety.

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