Joint Commission: Vial misuse harming thousands of patients

July 7, 2014

The misuse of single-dose and multiple-dose vials has harmed thousands of patients, in some cases causing bloodborne pathogens including hepatitis B and C, meningitis, and epidural abscesses, according to the Centers for Disease Control and Prevention.

The misuse of single-dose and multiple-dose vials has harmed thousands of patients, in some cases causing bloodborne pathogens including hepatitis B and C, meningitis, and epidural abscesses, according to the Centers for Disease Control and Prevention (CDC).

According to the CDC, the misuse has occurred in both inpatient and outpatient settings, and primarily involves the reuse of single-dose vials. Since single-dose vials usually lack preservatives, using them more than once increases risks of bacterial contamination and infection. The findings were published in a Sentinel Event Alert from the Joint Commission.

“[CDC] is aware of at least 19 bloodborne or bacterial infection outbreaks since 2007 association with the misuse of single-dose/single-use vials,” the alert stated. “Seven involved bloodborne pathogen infections, and 12 were bacterial infections. All of these occurred in the outpatient setting, with eight occurring in pain remediation clinics.”

Since 2001, at least 49 outbreaks have been attributed to the mishandling of injectable medical products, according to CDC. Twenty-one of those outbreaks involved hepatitis B or C. CDC said the other 28 outbreaks were bacterial infections.

Most of the outbreaks happened in pain management clinics and in cancer clinics. As a result of the misuse of the vials, CDC said 150,000 patients had to be notified and advised to have pathogen testing.

As part of the alert, The Joint Commission is reemphasizing its requirements regarding the use of vials, as well as a graphic illustrating safe-injection practices for multiple-dose vials.