Injection Safety.

Safe Injection.


Safe injection is an injection that does no harm to the recipient, does not expose the health worker to any risk and does not result in waste that puts the community at risk as per WHO definition. And injection safety includes all actions that are needed to ensure safe injection.
Injection safety is a basic expectation in patient care.
Safe practices should not be sacrificed in efforts to save time or money.
The common causes of an unsafe injection for patients are:
1. needle prick from a used syringe. .
2. infected syringes or needle which is the result of reuse of syringes after inadequate sterilization and repacking of used syringes by illicit groups..
3. poor technique.
4. infected vials.
The common causes of an unsafe injection for community and health worker are
1. improper or inadequate destruction of used syringes.
2. unsafe disposal of sharps or needles.
3. careless handling and unscientific management of used syringes and needles.

As the patient’s safety is in the hands of medical staff, they always exert utmost care to save and protect the precious lives entrusted in their hands.
On one side, a careless health worker can inject a fatal disease like HIV or hepatitis into a patient by mistake. On the other side a health worker can get infection from a patient while executing his or her duties sincerely. Both these incidents are most unfortunate. And all possible precautions should be taken to prevent these forbidden events.


Patient safety

Injection safety is basically provided by qualified medical staff. Patient can only expect safe and efficient care by his or care taker.
Safe practices should not be sacrificed in efforts to save time or money by the medical staff. A well known saying about injection safety is that:
“If you have to justify or qualify your injection practices, you might be doing something wrong!”

Strictly follow safe injection practices to ensure safe patient care.

Safe injection is an injection that does no harm to the recipient, but the definition also extends as, the one that does not expose the health worker to any risk. WHO definition further extends to include the community and says that, it should not result in wastes that put the community at risk.

The original syringe that was used for decades was Sterilizable syringe- either all plastic or all glass syringe with steel needle. This type of syringe was designed for re-use after proper cleaning and sterilization in a steam sterilizer or autoclave. The use of these syringes is associated with infection with the emergence of blood borne diseases and so is not recommended.

New technology devices that prevent potential infections are:

Auto-disable (A-D) 1 syringe : A specially modified plastic syringe with a fixed needle which is automatically disabled after a single use.

Syringe with reuse-prevention feature :A specially modified plastic syringe that includes a mechanism to discourage reuse.
Jet injector : A needle-free device that allows the injection of a substance through the skin under high pressure.
Safety syringe :Modified, disposable plastic syringe designed so that the health care worker can disable it in such a way that the needle is protected and cannot be re-used.
Peanut Safe syringe: Modified, disposable plastic syringe, new to the market designed so that the health care worker can disable both the needle and barrel after use and cannot be re-used. The product stands out because of cost effectiveness.

Universal precautions are intended to prevent the exposure of health-care workers and patients to bloodborne pathogens. These must be practised in regard to the blood and body fluids of all patients, regardless of their infection status.

Universal precautions include:

Hand-washing before and after all medical procedures
safe handling and immediate safe disposal of sharps:
not recapping needles;
using special containers for sharp disposals;
Using needle cutter/destroyers; or auto disable syringes.
Using forceps instead of fingers for guiding sutures;
using Vacationers where possible Safe decontamination of instruments;
Use of protective barriers whenever indicated to prevent direct contact with blood and body fluid such as gloves, masks, goggles, aprons, and boots.
A helath care worker who has a cut or abrasion should cover the wound before providing care.
Safe disposal of contaminated waste

KEY TRAINING MESSAGES FOR INJECTION SAFETY IN IMMUNIZATION PROGRAM

  • Use a sterile AD syringe and needle to vaccinate each child.
  • Use a disposable syringe and needle to reconstitute each vaccine.
  • Prevent contamination of injection equipment and vaccine.
  • Prepare each injection in a designated, clean area where blood or body fluid contamination is unlikely.
  • Always pierce the septum of multi-dose vials with a sterile needle.
  • Do not leave a needle in the stopper.
  • Protect fingers with small gauze pad when opening ampoules.
  • Discard a needle that has touched any non-sterile surface (hands, environmental surfaces).
  • Anticipate and take measures to prevent sudden patient movement during and after injection.
  • Prevent needlestick injuries by not recapping, and placing used needles directly in safety boxes.
  • Collect used syringes and needles at the point of use in a safety box, that is sealed when full (do not transfer contents or overfill safety boxes).
  • Seal safety boxes for transport to a secure area. Do not open, empty or reuse them.
  • Manage injection waste in an efficient and environment-friendly way.
  • Prevent accidents to personnel in charge of waste disposal.
  • Do not place empty vials in the safety box, they may explode while burning.
  • Put only potentially contaminated injection equipment in the safety boxes. Do not put empty vials, cotton pads, compresses, etc. in the safety boxes.

Burden of unsafe injections are really huge

Total number of injections per annum in developing and transitional countries is 16 billion as per WHO

Diseases most frequently contracted through unsafe injection practices
  • Hepatitis B (21 million cases annually): 32% of incidence
  • Hepatitis C (2 million cases annually):40% of incidence
  • HIV AIDS: 5% of incidence: 5% of incidence
Estimated proportion of syringe and needle re-use by WHO Region
European : 1-11%
Eastern Mediterranean : 70%
South East Asian: 30-75%
Western Pacific: 30%
African: 17-19%%
Americas (Central and South): 1-11%
From the patient’s side, injection safety is a basic expectation from medical care providers and the only way to ensure it is by seeking care from well trained and dedicated medical personnel.


Hospital staff safety

Hospital staff are highly prone for accidental contamination by blood born diseases as they have to handle potentially highly infective materials as part of their duty.

Health care person is at the risk of infection when there is:
-a percutaneous injury (e.g. needle-stick or cut with a sharp instrument),
-contact with the mucous membranes of the eye or mouth,
-contact with non-intact skin (particularly when the exposed skin is chapped, abraided, or afflicted with dermatitis)
-contact with intact skin when the duration of contact is prolonged (e.g. several minutes or more) with blood or other potentially infectious body fluids.
Certain work practices increase the risk of needlestick injury such as:
Recapping needles (Most important).
Transferring a body fluid between containers.
Failing to dispose of used needles properly in puncture-resistant sharps containers.
Poor healthcare waste management practices

Methods to protect oneself from needlestick/sharps injuries:
Avoid the use of needles where safe and effective alternatives are available.
Avoid recapping needles.
Plan for safe handling and disposal of needles before using them.
Promptly dispose of used needles in appropriate sharps disposal containers.
Report all needle stick and sharps-related injuries promptly to ensure that you receive appropriate follow-up care. Participate in training related to infection prevention.
Help your institute select and evaluate devices with safety features that reduce the risk of needle stick injury.
Use devices with safety features provided by the institute (wherever possible).
Record and monitor injuries with an injury register in each location of healthcare setting.

Devices with Safety Features are recommended for better protection

Improved engineering controls are often among the most effective approaches to reducing occupational hazards and therefore are an important element of a needlestick prevention program. Such controls include eliminating the unnecessary use of needles and implementing devices with safety features. A number of sources have identified the desirable characteristics of safety devices.

These characteristics include the following:
  • The device is needleless.
  • The safety feature is an integral partof the device.
  • The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the worker.s hands to remain behind the exposed sharp.
  • The user can easily tell whether the safety feature is activated.
  • The safety feature cannot be deactivated and remains protective through disposal.
  • The device performs reliably.
  • The device is easy to use and practical.
  • The device is safe and effective for patient care.
Although each of these characteristics is desirable, some are not feasible, applicable or available for certain health care situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should thus serve only as a guideline for device design and selection

Examples of Safety Device Designs

Few examples of safety device designs are listed as follows:
  • Needleless connectors for IV delivery systems (e.g., blunt cannula for use with prepierced ports and valved connectors that accept tapered or luer ends of IV tubing)
  • Protected needle IV connectors (e.g., the IV connector needle is permanently recessed in a rigid plastic housing that fits over IV ports)
  • Needles that retract into a syringe or vacuum tube holder
  • Hinged or sliding shields attached to phlebotomy needles, winged-steel needles, and blood gas needles
  • Protective encasements to receive an IV styled as it is withdrawn from the catheter
  • Sliding needle shields attached to disposable syringes and vacuum tube holders
  • Self-blunting phlebotomy and winged steel needles (a blunt cannula seated inside the phlebotomy needle is advanced beyond the needle tip before the needle is withdrawn from the vein.see Figure 3)
  • Retractable finger/heel-stick lancets

Needle Prick

Needle prick is possibly the most common cause of transmission of fatal diseases in a health care setting.
A contaminated needle has high potential for disease transmission.
Most common occupational and iatrogenic transmission of blood borne diseases is through needle prick.
Contact to infective source by a needle prick is more likely to result in infection than by other forms of contamination.
Needle prick causes infection as it carries contaminated blood over it and inside its bore.
Any panic move can inject further amount of blood into the recipient.
Needle prick is considered more serious than an open wound, as the contaminated blood is deposited deep into the tissues and the track is closed by tissue tension making it not amenable to clean with detergents.
Causes of percutaneous needle injuries as per Center for Disease Control, America
i. Handling and transferring specimens-5%
ii. Improper disposal of sharp- 10%
iii. Manipulating needle in patient -27%
iv. Handling and passing device during /after use-10%
v. IV line related causes-8%
vi. Recapping -5%
vii. Clean up-11%
viii. Disposal related causes 12%
ix. Bumping into sharp or other causes -8%
x. Others -4%
In studies where the contaminated needle contains significant amount of blood (0.5ml), the pathogen was found to survive over a month.
Needle borne transmission can occur in three patterns:
  • from patient to patient.
  • from patient to health care personnel.
  • from health care personnel to patient.
It is most unfortunate, if a person with a mild disease or accident gets infected with an incurable fatal disease as he seeks cure in a medical set up.
A person can get infected through a needle stick if the syringe is pre-contaminated.
This occurs when the syringe is reused.
A medical device, if has to be re-used needs to be sterilized by:
-autoclaving.
-physical agents like UV.
-Chemical agents with their specified time of contact. Eg.: ETO, xydex.
Estimated percutaneous injuries as per Center for Control of Diseases from different type of sharps are given below :
  • Winged steel needle -13%
  • Hypodermic needle – 29%
  • IV styllet - 6%
  • Phlebotomy needle – 4 %
  • Suture needle -15 %
  • Other hollow bore needle -10 %
  • Other sharp – 6%
  • Glass - 17%
Maximum disease transmission occurs at rooms where there is need for quick actions.
• emergency departments
• ICU
• Labor rooms
Here without realizing that the device is once used, it may be reused under pressure of emergency.
Even if the mistake is identified immediately, the correction of the mistake is not easy



Infected Vails

Infected vials are a new concern in injection safety when multi dose vials are being used. If any patient’s blood contaminated with a transmissible disease is accidently injected to this vials, by a reused syringe or needle the whole vial become a sourced of injection. Following this irrespective of the usage of fresh or old needle this transmits the disease agent in it to all the following injections. If this vial is further contaminated by another contaminated syringe or needle, both these diseases can be transmitted to the recipients in every following injection.

Multi-dose medications should be:
  • Dedicated single-patient to single patient, whenever possible
  • Entered only with sterile needle and sterile isyringe
  • Dated upon initial entry and discarded within 28 days of opening or according to manufacturer’s instructions
  • Discarded if sterility is compromised
Multi-dose medications should not be kept in the immediate patient treatment area.