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“You Could Have Heard a Pin Drop.” Kent Hospital Renews Vigilance on Injection Safety Rules

Posted on by CDC's Safe Healthcare Blog
Peter Graves MD
Peter Graves MD

Guest Author – Peter Graves, MD
Chairman, Department of Emergency Medicine
Academic Faculty, Kent Hospital Emergency Medicine Residency Program
Kent Hospital
Warwick, RI

One of the great “truisms” of Life is that we often don’t know—what we don’t know. In other words, we can’t imagine the scope of a problem if we are under the assumption that it doesn’t even exist.

No provider goes to the hospital or office with the intent of harming patients. So I was shocked to learn that the Centers for Disease Control and Prevention has tracked over 40 outbreaks of infectious disease caused by unsafe injection practices including hepatitis B (HBV), hepatitis C (HCV) and bacterial infections in the past 10 years in the United States. It is fundamentally unacceptable that these outbreaks were because healthcare providers failed to follow Standard Precautions when preparing an injection. Those lapses in basic infection control include reusing needles and syringes from patient to patient or misusing single-dose and multi-dose vials. This boggles the minds of many practitioners who may feel they are following correct procedures—when in fact they might not be doing so at all.

In fact, the CDC and Safe Injection Practices Coalition (SIPC) say that over 130,000 patients have been notified that they might be at risk for bloodborne disease, due to these unsafe practices. And that number may just be the tip of the iceberg, because of the lag between exposure and diagnosis of the disease. Sometimes the source is impossible to trace. And these outbreaks, except for a few instances, don’t make the nightly national news.

Though we’ve never had an outbreak or known infection, establishing a culture of safety around these potential sources of infection is not just about procedure, it’s about trust and sleeping well at night.
So, Kent Hospital’s Continuing Medical Education (CME) program designed an activity to improve physician knowledge, competence and performance of safe injection practices. This CME intervention also met the Rhode Island requirement for Blood borne Pathogens education, necessary for physician re-licensure. We drew on the Safe Injection Practices Coalition’s “One & Only Campaign”, whose slogan is “One Needle, One Syringe, Only One Time.” Evelyn McKnight, who was one of 99 persons infected with hepatitis C after an outbreak in her Nebraska town in 2002, shared her poignant personal story. She was being treated for a recurrence of breast cancer, only to contract hepatitis C because a provider used one IV bag as a shared source of flush for multiple chemotherapy patients. Her husband, Dr. Tom McKnight shared his story of the medical “detective” work that allowed him to put together why so many people in their small community were contracting hepatitis C.

You could have heard a pin drop as these stories were told to over one hundred physician attendees. And I am happy to say, our reaction, as a hospital was swift and decisive. The next day, as Chairman of the Department of Emergency Medicine, I re-emphasized existing hospital rules on injection preparation and handling vials of medicine and added a rule on suture carts. All nursing staff, residents, ED physicians and other ancillary staff must:

  • Discard any opened vials of local anesthetic, sodium bicarbonate or any other medication found in a procedure cart or patient area, after the medication has been used
  • Consider all medication as single use vials and discard after use
  • Affix procedure cart warnings to suture carts stating all vials are to be discarded after use

The “conversation” has now begun, here at Kent. From individual physicians to nurses, to Infection Prevention and Control, we are looking at new ways to be vigilant about ensuring that one needle and one syringe are used each and every time an injection is administered.

We applaud the SIPC’s “One & Only Campaign” and encourage all hospitals to sign on to it. Don’t wait for an adverse event to happen. These are eminently preventable transmissions of HAIs. They don’t have to happen.

Posted on by CDC's Safe Healthcare Blog

5 comments on ““You Could Have Heard a Pin Drop.” Kent Hospital Renews Vigilance on Injection Safety Rules”

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    Many people have lost their lives due negligence. Proper care needs to be taken. Proper training, education are essential as tea is needed in the morning.

    Thanks for the sharing the article. the patient care in hospital is mandatory. Many people suffers from bone cancer diseases due o the unsafe in the hospital.

    Very interesting post, and you’re right – we just don’t know what we don’t know. Unfortunately most of these simple procedures are taught in training from day one, so either follow-up training isn’t being adhered to or provided, or people are simply cutting corners through staff shortages, stress or lack of appropriate materials. Domiciliary care is fraught with potential for accidents and error – the best way to prevent this is proper education and regular, stringent assessments on how well staff are taking this important information on board.

    Katie – Apex Health + Social Care

    Facilities like the VA Medical centers in Oklahoma and the State Health Department are still using “mult-use” vials to administer various medications, including mass flu inoculations. A large number of those infected with HCV are veterans and yet this continues as standard operating procedure.

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