Ensure Safe Medication Practices in a Surgery Center: Practical Solutions and Rules Overview

The following article is written by Pamela Dembski Hart, CHSP, BS, MT (ASCP), principal of Healthcare Accreditation Resources.

The nation is witnessing an alarming growth of patient-to-patient transmission of infectious diseases in outpatient settings. In the last decade, as many as 150,000 patients in the United States were notified of potential exposure to hepatitis B virus, hepatitis C virus and HIV due to lapses in basic infection control practices in healthcare settings.(1) Reports of these type of incidents continue to occur almost daily. The majority of these cases derive from the reuse of a syringe intended for a single use, the re-entry into a vial intended for a single-dose administration and inadequate or improper sterilization or disinfection of patient care equipment.

Also, a recent survey conducted (2) of approximately 6,000 healthcare providers demonstrated recurrent misconceptions and errors regarding infection prevention and safe injection practices. These results serve as a reminder that unacceptable practices continue despite efforts to enhance adherence to infection prevention guidelines. Increased education and oversight is paramount to improve compliance and decrease the incidence of bloodborne disease transmission from these unsafe injection practices. Here are five critical areas ambulatory surgery centers should focus on and steps to follow to help achieve and maintain medication safety and safe injection practices.

1. Single-dose vials

• Follow aseptic technique and use for one patient only.
• Enter only once, for one procedure.
• Enter using a new, clean needle and new, clean syringe.
• Never use on additional patients.
• Discard any medication remaining in the vial at the end of the procedure.
• Select the smallest vial size available when purchasing.
• Do not pool unused contents from single use vials.
• Discard unopened vial according to manufacturer expiration dates.

According to the Institute for Safe Medication Practices, the size of the single-use vial or the volume contained within does not absolve the clinician from adhering to the requirements as listed above. Large volume (as seen with the drug propofol) does not make it suitable for multi-patient use. Single-use vials traditionally do not contain preservatives to prevent microbial growth, which may occur after the initial entry into the vial.

2. Multi-dose vials

• Must be labeled by the manufacturers as a multi-dose vial.
• Follow aseptic technique. Cleanse the access diaphragm of vials using friction and a sterile 70 percent isopropyl alcohol, or other approved antiseptic swab. Allow the diaphragm to dry before inserting any device into the vial.
• If used for more than one patient, use with new needle and new syringe.
• Do not reuse syringes. Pathogenic contamination is not visible to the naked eye and enters the syringe after injection.
• Do not access multi-dose vials in the immediate patient area (e.g., treatment area, OR, patient rooms or bays). This means withdraw medication in an area segregated from patient care (medication room or area separated by a wall or screen).
• Label with 28-day expiration (discard) date upon opening or withdrawing first dose. Discard unopened vials according to manufacturers' expiration dates. Note: Some expiration dates for opened vials may be shorter than 28 days and must be disposed of accordingly.
• A needle or other device should never be left inserted into a medication vial septum for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid.

3. IV bags/prefilled syringes

• Do not use bags or bottles of IV solutions as a general supply for multiple patients.
• Once the bag is spiked, use within one hour. Discard tubing and bag. Note: According to APIC, this is an unresolved issue and recommends use as close as possible to spiking bag. Never spike the bag the night or even hours before anticipated use.
• Same syringe cannot be used for multiple patients to inject medications into an IV tubing port that is several feet away from another patient's IV catheter site.
• Everything from the medication bag to the patient's catheter is a single interconnected unit. All of the components are directly or indirectly exposed to the patient's blood and cannot be used for another patient.
• A syringe that intersects through ports in the IV tubing or bags also becomes contaminated and cannot be used for another patient. Separation from the patient's IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items.
• Pre-filled syringes/medications that are pre-drawn are labeled with the time of draw, initials of the person drawing, medication name, strength and expiration date or time. All pre-filled syringes not for immediate use must be labeled as indicated above.

4. Insulin pens

• Insulin pens containing multiple doses of insulin are meant for use by a single patient only, and are not to be shared between patients.
• Identifying the insulin pen with the name of the patient and other patient identifiers provides a mechanism for verifying that the correct pen is used on the correct patient, and can help minimize medication errors.
• Disposable needle should be ejected from the insulin pen and properly discarded after each injection. A new needle should be attached to the insulin pen before each new injection.
• Patients should be advised that sharing of their insulin pens could result in transmission of hepatitis viruses, HIV or other bloodborne pathogens.

5. Adhere to safe injection practices

The following is recommended:

• Designate someone to provide ongoing oversight for infection control issues.
• Develop written infection prevention and control policies.
• Provide training.
• Conduct quality assurance assessments.
• Store all medication according to manufacturers' temperature requirements.

Learn more about Healthcare Accreditation Resources.

References

1) Safe Injection Practices Colition and Safe Injection Policy Task Force/HONOReform

2) Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38:789- 98). www.premierinc.com/injectionpractices.