Preventing Unsafe Injection Practices

The following safe injection practices are critical for patient safety:

• Always use aseptic technique when preparing and administering injections.
• Use a new sterile syringe and needle for each patient. Once used, the syringe and needle are both contaminated and must be discarded.
• Do not 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.
• Do not enter a medication vial, bag, or bottle with a syringe or needle used on another patient.
• Never use medications intended for single use for more than one patient. This includes single-dose vials, ampoules, bags and bottles of intravenous solutions.
• Limit the use of multi-dose vials and dedicate them to a single patient whenever possible. Reused multi-dose vials should be kept and accessed in a designated clean medication preparation area, away from immediate patient treatment areas.
• Always use facemasks when injecting material or inserting a catheter into the epidural or subdural space.

Draw up medications in a designated clean medication preparation area that is not adjacent to potential sources of contamination, including sinks or other water sources.

Clean and disinfect the medication preparation area on a regular basis and any time there is evidence of soiling. Have supplies (e.g., alcohol-based hand rub, needles and syringes in their sterile packaging and alcohol wipes) available in the medication preparation area to ensure that staff can adhere to aseptic technique.

The safest practice is to prepare an injection as close as possible to the time of administration. This reduces the risk of compromising the medication's:

• Sterility: microbial contamination or proliferation.
• Physical and chemical stability: the loss of potency or adsorption to the container.

If there is a need for pre-drawn syringes, one option is to purchase conventionally manufactured pre-filled syringes. These syringes undergo quality assurance, including sterility and stability, testing by the manufacturer. Another option is to obtain pre-filled syringes from an FDA-registered outsourcing facility. Outsourcing facilities are subject to current good manufacturing practice requirements and other requirements to help assure drug quality.

Do not leave a needle inserted into a medication vial septum for multiple uses. This creates a direct route for microorganisms to enter the vial and contaminate the fluid.

Always discard medication vials whenever sterility is compromised or questionable.

Certain types of manipulation as part of medication preparation may be considered pharmaceutical compounding. Examples include combining two or more medications or creating a batch of pre-drawn syringes. For more information, refer to United States Pharmacopeia (USP) General Chapter 797 and the Sterile compounding section below.14

A single-dose vial of liquid medication intended for injection or infusion is only approved for use in a single patient for a single case, procedure or injection.

Single-dose vials are labeled by the manufacturer and typically lack an antimicrobial preservative. They can serve as a source of infection when used inappropriately or contaminated.

Never use medications packaged as single-dose vials for more than one patient. Consult with pharmacy professionals and USP 797 standards if there is a need to subdivide contents of single-dose vials.

If a single-dose vial appears to contain multiple doses or contains more medication than needed for a single patient, do not retain it for future use, even on the same patient.

Do not combine (pool) leftover contents of single-dose vials or store single-dose for later use.

To prevent waste or the urge to use contents from single-dose vials for more than one patient, select and purchase the smallest vial necessary for your needs.

Discard an unopened single-dose vial according to the manufacturer's expiration date.

A multi-dose vial of liquid medication contains more than one dose of medication and is approved for repeated uses.

Multi-dose vials are labeled by the manufacturer and typically contain an antimicrobial preservative to help limit the growth of bacteria. The preservative does not have an effect on viruses nor does it provide complete protection against bacterial contamination.

Assign medications packaged as multi-dose vials to a single patient whenever possible.

Multi-dose vials that are used for more than one patient should be kept and accessed in a clean medication preparation area away from immediate patient treatment areas.

If a multi-dose vial enters an immediate patient treatment area, dedicate it for single patient use only. Examples of immediate patient treatment areas include operating and procedure rooms, anesthesia and procedure carts, and patient rooms or bays.

The United States Pharmacopeia (USP) General Chapter 797 recommends the following

• An unopened multi-dose vial should be discarded according to the manufacturer's expiration date.
• Once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date.14

For information on storage and handling of multi-dose vaccine vials please refer to the CDC Vaccine Storage and Handling Toolkit or the manufacturer's recommendations.