Sentinel Event Alerts

Preventing infection from the misuse of vials.

Commission J. Sentinel event alert. 2014:1-6.

The Joint Commission has issued a sentinel event alert regarding infections caused by the misuse of vials, prompted by at least 49 outbreaks related to this problem since 2001. The reuse of single-dose vials has resulted in documented transmission of bacteria and hepatitis B and C viruses. Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management and cancer clinics. More than 150,000 patients required notification and further testing due to concern of potential exposure to unsafe injections. This alert outlines recommendations and potential strategies for improvement, including resources related to the Centers for Disease Control and Prevention's (CDC) One & Only Campaign, which promotes using "one needle, one syringe, only one time." The report also emphasizes teaching safe practices and establishing safety culture. CDC has previously issued guidelines on appropriate use of single-dose vials.