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Patient Notification Events Due to Syringe Reuse and Mishandling of Injectable Medications by Health Care Personnel—United States, 2012–2018

Summary and Recommended Actions for Prevention and Response
Published:December 26, 2019DOI:



      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.


      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.


      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:

      CDC (Centers for Disease Control and Prevention), HCV (hepatitis C virus)
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      Linked Article

      • Injection Safety in the United States: Miles to Go?
        Mayo Clinic ProceedingsVol. 95Issue 2
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          Injections 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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