The infection risk posed by the misuse of medication vials is underestimated, says the Joint Commission in its latest Sentinel Event Alert, which casts a spotlight on the issue of injection safety.
"Due to the difficulty of tracing the misuse of vials to infections, the adverse impact of misusing a vial is typically not seen immediately," the alert notes. "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."
In its alert, issued last week, the Joint Commission counts at least 49 outbreaks of bloodborne viruses and bacterial infections since 2001 that have been linked to the mishandling of single-use and multiple-dose vials. It attributes these incidents to healthcare providers' lapses in infection control techniques, especially with regard to the reuse of single-dose vials, the reuse of syringes in multiple-dose vials, and the preservative-free medications that are at greater risk of contamination.
While these lapses are often the result of staff's efforts to prevent waste in a time of drug shortages and spiraling costs, "any cost savings achieved by preventing waste can quickly be offset by one or more adverse clinical outcomes," says the alert.
The Joint Commission recommends that facilities put standardized drug handling policies into place, routinely educate staff on these policies, keep an eye out for open vials, emphasize the importance of and follow through on error reporting, and respond to incidents with risk analysis, patient notification and testing.