Safe injection practice

Aminu M Hussain
 Introduction
• It is important to note that some people
reserve the word injection for a procedure in
which a medication, vaccine or other solution
is deposited into to a patient, while other
people use the word injection in a more
general sense that includes needle insertions
either to deposit these types of fluids into a
patient or withdraw blood or other bodily
fluids.
 Definition
• “A safe injection, phlebotomy, lancet
procedure or intravenous device insertion does
not harm the recipient, does not expose the
provider to any avoidable risk and does not
result in any waste that is dangerous for other
people.”
 Procedure types:
• 1. Intradermal, subcutaneous and
intramuscular needle injections;
• 2. Dental injections;
• 3. Phlebotomies;
• 4. Lancet procedures; and,
• 5. Intravenous infusions and injections
Infections from unsafe injection practices

• Blood borne pathogens such as hepatitis B and

hepatitis C can be spread through unsafe
injection practices.
• Outbreaks of these diseases have occurred as
a result of contamination of multiple dose
vials of medication or containers of IV fluid, as
well as misuse of blood glucose monitoring
devices.
 What is safe injection practices?
• A Safe injection practices include:
• Use aseptic technique to prevent contamination of sterile
injection equipment.
• Do not administer medications from a single syringe to multiple
patients. Changing the needle is not sufficient.
• Use fluid infusion and administration sets (i.e., intravenous
bags, tubing, and connectors) for one patient only and discard
immediately after use.
• Use single-dose vials for injectable medications whenever
possible.
• If multi-dose vials must be used, use and store them in
accordance with the manufacturer’s instructions.
 ACTIONS THAT HELP PREVENT UNSAFE
INJECTION PRACTICES:
• 1. Quality assurance, Infection Prevention and control, Risk
Management unit: to periodically observe injection practices by
all healthcare personnel responsible for medication preparation
and administration.
• 2. All healthcare personnel should receive regular education and
training regarding safe injection practices. Education is
particularly important considering researches that has shown the
many misconceptions held by healthcare personnel in relation to
injection safety.
• 3. Look at the various medication preparation areas throughout
your facility. Critically assess the med prep area to ensure it isn’t
adjacent to any potential source of contamination, within 3 feet of
a sink, or in a cluttered environment.
 GUIDELINES FOR INJECTION SAFETY
• The specific guidelines for injection safety from the
CDC are:
• 1. Follow proper infection control practices and
maintain aseptic technique during the preparation
and administration of injected medications.
• 2. Never administer medications from the same
syringe to more than one patient, even if the needle
is changed or you are injecting through an
intervening length of IV tubing.
• 3. Never enter a vial with a used syringe or needle.
• 4. Do not use medications packaged as single-
dose or single-use for more than one patient.
• 5. Do not use bags of intravenous solution as a
common source of supply for more than one
patient.
• 6. Limit the use of multi-dose vials and
dedicate them to a single patient whenever
possible.
• 7. Do not keep multi dose vials in the immediate patient
treatment area. Medications should be prepared in an
area that is free from contamination on a clean work
surface.
• Outbreaks have been linked to preparing medications in
areas contaminated with blood or body fluids as well as
in the same area that (used) syringes are disassembled.
• 8. Always use facemasks when injecting material or
inserting a catheter into the epidural or subdural space.
• The CDC’s One and Only Campaign motto of
“One needle, one syringe, only one time”
underlines the importance of never reusing a
syringe and/or needle – not even to obtain
medication for the same patient.
 Best Infection Control Practices for
injections
• 1. Use sterile devices:
• i. Use a new sterile single-use device for each procedure.
• ii. Use a new sterile single-use syringe and needle to
reconstitute each unit of medication or vaccine.
• iii. Inspect packaging of devices for breaches in barrier
integrity. Discard any device if the package has been
punctured, torn, or damaged by exposure to moisture or if
the manufacturer’s expiration date has already passed.
• iv. Maintain an adequate supply of single-use devices to
enable providers to use new devices each time they
perform a procedure.
 2. Prevent contamination of devices,
medication and fluids for infusion:
• i. Prepare procedures in a clean, dedicated table or tray where
contamination of the equipment with blood, body fluids or
dirty swabs is unlikely.
• ii. Never leave a needle in place in the stopper of the vial.
• iii. Use single-dose vials rather than multi-dose vials whenever
possible.
• iv. If multi-dose vials must be used, always pierce the septum
with a sterile needle.
• v. Select pop-open ampoules rather than ampoules that require
use of a metal file to open whenever possible.
• vi. In all cases, protect fingers with a clean barrier (e.g., small
gauze pad) when opening the ampoule.
• vii. Inspect for and discard medications and fluids for
infusion with visible contamination (e.g., cloudy) or
breaches of integrity (e.g., cracks, leaks) or which are
expired.
• viii. Follow product-specific recommendations for use,
storage (including maintenance of the cold chain where
needed), and handling.
• ix. Discard a needle that has touched any non-sterile
surface.
• x. Ensure that reusable phlebotomy holder-adapters
used for performing phlebotomies are clean.
 3. Prevent needle stick and sharps injuries
to the provider:
• i. Anticipate and take measures to prevent sudden patient
movement during and after performing a procedure.
• ii. Avoid recapping and other hand manipulations of needles.
If recapping is necessary, use a single-handed scoop technique
for recapping.
• iii. Collect used sharps at the point of use in a sharps container
that is puncture and leak proof and that can be sealed-shut
when ¾ full.
• iv. Maintain an adequate supply of sharps containers that are
puncture and leak-proof to enable providers to always have a
sharps container available when they perform a procedure.
 4. Prevent access to used devices:
• i. Seal sharps containers and containers for infectious
non-sharps waste for transport to a secure area in
preparation for disposal. After closing and sealing these
containers, do not open, empty, reuse, or sell them.
• ii. Manage sharps waste and infectious non-sharps waste
in an efficient, safe, and environmentally friendly way to
protect people from voluntary and accidental exposure
to used devices including ensuring that there are no
loose, used devices anywhere inside or outside the
facility or in open or overflowing sharps containers or
infectious non sharps waste containers.
 Other practice issues
• 1. Engineered technology: Whenever possible, use
devices with safety features that are activated
either automatically or manually which are
designed to prevent reuse and needle stick injuries
and which have been shown to be effective in
protecting patients and providers.
• Auto-disable (AD) syringes prevent reuse of
injection equipment, and should be the only type
of injection equipment used in immunization
services.
• 2. Provider's hand hygiene and skin integrity: Perform
hand hygiene (i.e., wash or disinfect hands) prior to
preparing injection material and giving injections.
• The need for hand hygiene between injections will
vary based on whether there was contact with soil,
blood or body fluids.
• Avoid giving injections if skin integrity is compromised
by local infection or other skin condition (e.g.,
weeping dermatitis, skin lesions or cuts).
• Cover any small cuts on health care provider's hands.
• 3. Gloves: Gloves are not needed for intramuscular, subcutaneous
and intradermal injections.
• Single-use gloves may be indicated if excessive bleeding is
anticipated or when performing intravenous device insertions,
infusions or phlebotomies.
• 4. Swabbing of vial tops or ampoules: Swabbing of vial tops or
ampoules with an antiseptic or disinfectant is unnecessary. If
swabbing with an antiseptic is selected for use, use a clean, single
use swab and maintain product-specific recommended contact
time.
• Do not use cotton balls stored wet in a multi-use container, and do
not use an antiseptic where preparing a vaccination with a live
attenuated virus.
• 5. Skin preparation prior to intramuscular, subcutaneous, and intradermal
injections and lancet procedures: Wash skin that is visibly soiled or dirty.
• Swabbing of the clean skin prior to giving an injection is unnecessary. If
swabbing with an antiseptic is selected for use, use a clean, single-use
swab and maintain product-specific recommended contact time. Do not
use cotton balls stored wet in a multi-use container, and do not use an
antiseptic where preparing a vaccination with a live attenuated virus.
• 6. Skin preparation prior to intravenous device insertions, including
phlebotomy, intravenous injections, infusions, and intravenous catheter
insertions: Cleanse skin at the intended puncture site and injection ports
with 2% chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol,
and allow drying prior to performing the procedure.
• 7. Insertion of needles into existing intravenous
systems: Only use injection ports as a site for entry into
the intravenous system. Cleanse the injection ports
with 2% chlorhexidine, tincture of iodine, an iodophor,
or 70% alcohol, and allow drying prior to administering
an infusion into an existing intravenous system.
• 8. Guidelines and reminders of best practices: Ensure
that guidelines, job aids and reminders of these best
practices are available to providers to facilitate and
reinforce the safety of common invasive procedures.
 Unsafe injection
• Worldwide, an estimated 16 billion injections
are administered every year.

• In 2010, unsafe injections were still

responsible for as many as 33,800 new HIV
infections, 1.7 million hepatitis B infections,
and 315,000 hepatitis C infections.
 Factors
• Economic
• Availability of equipment such as functional
sterilizer, refrigerator
• Accessibility to service
• Level of education
• Consumer choice
• Training of the provider
 Causes
• Lack of awareness of the risks
• Overuse of injections for illnesses for which
effective oral medications exist
• Needle stick injuries to health workers
• Lack of clean space
• Re use of syringes
• Unsafe sharps collection and waste
management
 Safety first
• For serous life threatening conditions
• When patients are unable to swallow
• When patient vomits profusely
• When there is no effective oral medication for
the condition
 Strategies
• Step 1: clean work space
• Step 2: hand hygiene
• Step 3: sterile and new syringe with re use
prevention
• Step 4: sterile vial of medication and diluent
• Step 5: skin disinfection
• Step 6: appropriate collection of sharps
• Step 7: appropriate waste management
 Complications
• Transmission of infectious diseases e.g.
hemorrhagic fevers, malaria, HIV
• Nerve damage
• Paralysis
• Skin abscess
• Injection abscess
• Phlebitis
 Questions
• What is safe injection
• What are the common causes of unsafe
injections
• What factors influence unsafe injections
• What are the complications
• What are the best measures