Abstract
Objectives
To summarize patient notifications resulting from unsafe injection practices by health
care personnel in the United States and describe recommended actions for prevention
and response.
Patients and Methods
We examined records of events involving communications to groups of patients, conducted
from January 1, 2012, through December 31, 2018, in which bloodborne pathogen testing
was recommended or offered because of potential exposure to unsafe injection practices
by health care personnel in the United States. Information compiled included: health
care setting(s), type of unsafe injection practice(s), number of patients notified,
number of outbreak-associated infections, and whether evidence suggesting bloodborne
pathogen transmission prompted the notification. We compared these numbers with a
similar review conducted from January 1, 2001, through December 31, 2011.
Results
From 2012 through 2018, more than 66,748 patients were notified as part of 38 patient
notification events. Twenty-one involved exposures in non-hospital settings. Twenty-five
involved syringe and/or needle reuse in the context of routine patient care; 11 involved
drug tampering by a health care provider. The majority of events (n=25) were prompted
by identification of unsafe injection practices alone, absent any documented infections
at the time of notification. Outbreak-associated hepatitis B virus and/or hepatitis
C virus infections were documented for 11 of the events; 8 involved patient-to-patient
transmission, and 3 involved provider-to-patient transmission.
Conclusions
Since 2001, nearly 200,000 patients in the United States were notified about potential
exposure to blood-contaminated medications or injection equipment. Facility leadership
has an obligation to ensure adherence to safe injection practices and to respond properly
if unsafe injection practices are identified.
Abbreviations and Acronyms:
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Article info
Publication history
Published online: December 26, 2019
Footnotes
For editorial comment, see page 216
Grant Support: The authors report no grant support for this report.
Potential Competing Interests: The authors report no competing interests. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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- Injection Safety in the United States: Miles to Go?Mayo Clinic ProceedingsVol. 95Issue 2
- PreviewInjections are an essential component of modern medicine. Pascal is credited with inventing the first modern syringe in 1650, although Roman and Greek literature alludes to syringe-like devices used both for medical procedures and for nonmedical purposes such as changing the pitch of musical instruments.1 Francis Rynd, an Irish physician, invented the hollow metal needle and used it to administer the first recorded subcutaneous injections in 1844. Today, needles and syringes are used for prevention (vaccines), diagnosis (contrast material, radioactive isotopes, and blood tests), and treatment (antibiotics, chemotherapy, insulin, sedatives, pain medications, and fluids) in various health care settings.
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