Pennsylvania Patient Safety Advisory Dangers Associated with Shared Multidose Vials Research shows that up to 25% of healthcare practi- healthcare-acquired infections, it does not address tioners re-enter vials with needles just injected into poor aseptic technique associated with multidose patients.1 There has been at least one report in vials. Healthcare organizations must recognize that PA-PSRS documenting this behavior, and similar through either lack of knowledge or poor technique, actions may not have been reported because prac- some practitioners routinely re-enter vials with used titioners may be unaware that routinely re-entering needles, without any realization they are likely con- vials with used needles and reusing syringes is placing taminating the contents of the vial. patients at risk for infection from contamination. Although the potential for time and cost savings is The consequence of sharing multidose vials was dra- apparent, multidose vial use in any patient care area matically illustrated by an occurrence elsewhere that is risky, with an ever-present danger for iatrogenic made national news. In February 2008, the South- cross-contamination. The safest practice is to use ern Nevada Health District reported findings from patient-specific vials and discard them immediately an investigation arising from a cluster of hepatitis after use. If multidose vials must be used, provide C virus (HCV) infections in their area. The health frequent staff education and monitor for proper district’s investigation uncovered that six patients infection control techniques. When a multidose vial infected with the HCV had undergone procedures at is used for an infected patient, transmission can be the Endoscopy Center of Southern Nevada. Genetic prevented by isolating the vial and using it exclusively testing on five of the cases identified a common for that patient.7 source, although the sixth patient did not share the same source.2 As a result of these infections, 40,000 Notes patients are being informed they should be tested for 1. Prott RT, Wagner RF, Tyring SK. Iatrogenic contamina- HCV, as well as for hepatitis B and HIV. As of May tion of multi-dose vials in simulated use. Arch Dermatol 2008, results show 77 individuals were likely exposed 1990 Nov;126(11):1441-4. to HCV from a procedure performed at the clinic. 2. Centers for Disease Control and Prevention. Epi-Aid These numbers are expected to rise since another Trip Report (2008-019): investigation of acute hepa- 10,000 patients have yet to be tested for the virus.3 titis C among patient who underwent procedures at clinic A: Nevada 2007 [online]. [cited 2008 May 23]. A full on-site investigation conducted by the Centers Available from Internet: http://health.nv.gov/docs/ for Disease Control and Infection, the Nevada State FinalEpi2_20080515.pdf. Health Division, and the Southern Nevada Health 3. Steinhauer J. 77 New cases of hepatitis are identified in District confirmed that during the past four years, Las Vegas. N Y Times [online]. 2008 May 9 [cited 2008 syringes were reused by practitioners to withdraw May 23]. Available from Internet: http://www.nytimes. additional doses of medication for the same patient; com/2008/05/09/us/09vegas.html. these findings substantiated that this practice was not 4. Vegas clinic may have exposed 40k to hepatitis, HIV a one-time occurrence.4 This technique most likely [online]. CNN.com 2008 Feb 28 [cited 2008 May 5]. contaminated the medication vial, and when used for Available from Internet: http://www.cnn.com/2008/ subsequent patients, the bloodborne pathogens in HEALTH/02/28/vegas.hepatitis.ap/index.html. the vial were inadvertently transmitted even though a clean needle and syringe were used. Since the 1970s, 5. Highsmith AK, Greenhood GP, Allen JR. Growth of reports of iatrogenic patient-to-patient transmission nosocomial pathogens in multiple-dose parenteral medi- of microbes due to contamination of multidose vials cation vials. J Clin Microbiol 1982 Jun;15(6):1024-8. have been well documented.5 Even when the multi- 6. Infectious Disease Branch, State of California Health dose vials are bacteriostatic, the vials still support and Welfare Agency. Multi-dose vials of Xylocaine-doses microbial growth; previously entered multidose vials re-use predispose to HBV or HIV transmission? Califor- exhibit viable organisms, and debris such as red blood nia Morbidity 1988 Nov 11. cells, epithelia cells, and lint fibers can be detected.6 7. Smetzer JL, Cohen MR. Preventing drug administration errors. Chapter 11. In: Cohen MR, ed. Medication errors While goal 7 of the Joint Commission National 2nd edition, American Pharmacological Association; Patient Safety Goals is intended to reduce the risk of 2007:261. Page 68 Reprinted©2008 Pennsylvania Patient Safety Authority Authority article - ©2008 Pennsylvania Patient Safety Vol. 5, No. 2—June 2008 pennsylvania Patient Safety Advisory This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 2—June 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. the pennsylvania patient safety authority and its contractors The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Patient Safety Authority, see the An Independent Agency of the Commonwealth of Pennsylvania Authority’s Web site at www.psa.state.pa.us. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.