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Sentinel Event Alert: Preventing Infection from Misuse of Vials

The Joint Commission has released a new issue of Sentinel Event Alert, a periodic publication on safety issues organizations should consider when designing or redesigning processes in their facilities. The current issue addresses preventing infection from the misuse of vials.

According to the Center for Disease Control and Prevention, there have been 49 outbreaks as a result of mishandling of injectable medical products since 2001. In a survey of nearly 5,500 healthcare professionals, published in the American Journal of Infection Control:

  • 6 percent admitted to sometimes or always using single-dose vials for multiple patients.
  • 15 percent reported using the same syringe for multiple uses with multiple-dose vials for the same patient. Of that 15 percent, 6.5 percent reported using the multiple-dose vial on another patient.
Read The Joint Commission's guidelines and recommendations for appropriate use of single- and multiple-dose/use vials, located on page three of the Sentinel Event Alert.

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