Sentinel Event Alert Issued on Infection Prevention From Misuse of Vials

By on 11:06 AM

The Joint Commission has issued a sentinel event alert (pdf) focusing on preventing infection from the misuse of single-dose/single-use and multiple-dose vials.

As The Joint Commission references, the Centers for Disease Control and Prevention reported last year that since 2001, at least 49 outbreaks have occurred because of extrinsic contamination of injectable medical products at the point of administration.

Of these 49 outbreaks, 21 involved transmission of the hepatitis B or hepatitis C virus. The other 28 represented outbreaks of bacterial infections, primarily invasive bloodstream infections. Approximately 90% of these known outbreaks occurred in outpatient settings.

The sentinel event alert publication identifies causes of misuse and then provides recommendations and strategies to consider for improvement in proper safe injection and infection control practices. It is a valuable resource that is worth reviewing closely and sharing with appropriate staff in your organization.

The publication also provides links to additional, helpful resources, including CDC's injection safety website and the One & Only Campaign from the CDC and Safe Injection Practices Coalition.


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