Regulatory Update - Infection Control Breaches Warrant Referral to Public Health Authorities

Note: The following regulatory updates are by Kirk Huslage, RN, BSN, MSPH, CIC

On May 30, 2014, CMS released a Survey and Certification Group memo reiterating the need for State Survey Agencies (SAs) or Accrediting Organizations (AOs) to report any identified breaches of generally accepted infection control standards as it relates to safe injection practices (see examples below) to the appropriate state public health authority (i.e., the State’s HAI Prevent Coordinator or Epidemiologist).

Is that a Single-Dose or Multi-Dose Vial? Imagine it was you!

by Marilee Johnson, MBA, MT (ASCP), Campaign Coordinator, NC One & Only Campaign, NC Division of Public Health

The information is clearly written on the label: Single-dose or multi-dose.  However, surveys have found that 6% percent of US clinicians admit to using single-dose vials for more than one patient.¹ In a recent assessment of infection prevention practices in ambulatory surgical centers, 28% percent of centers were found to reuse single-dose vials for more than one patient.² When you, as a healthcare worker, reuse a vial intended for only one patient, a person’s life and well-being are at stake.

It’s also important to remember that the preservatives in multi-dose vials have no effect on viruses and do not protect against contamination when healthcare personnel fail to follow safe injection practices. For this reason, even vials labeled as “multi-dose” should be dedicated to a single patient whenever possible.  If multi-dose vials must be used for more than one patient, they should never be kept or accessed in the immediate patient treatment area.³

Since 2001, at least 50 outbreaks involving unsafe injection practices have been reported to CDC, with 90% of these occurring in outpatient facilities.⁴ Misuse of multi-dose vials – including accessing a medication vial with a syringe that has already been used to administer medication to a patient – is one of the leading culprits.

If you do not believe that someone in your facility could harm your patients by misusing a multi-dose vial, I challenge you to read on.

In 2007, Johnny Robertson of Red Springs, NC, elected to have a preventative health care checkup. After all, he was turning 50 years old and it was time to have some preventative health screening.  His primary care provider recommended a few procedures, including a colonoscopy and a cardiac perfusion study.   Johnny followed this advice, scheduled the procedures and found the results were all good.  All was well and Johnny continued to donate blood regularly, as he had done for years. However,  when he donated blood this time (in 2007), he received an official letter from the Red Cross stating that he was infected with hepatitis C. Johnny was shocked because he did not have any known risk factors associated with hepatitis C.  He kept digging to see how he could have possibly gotten this awful disease.