Sentinel Event Alert on Reusing Vials

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Sentinel Event Alert on Reusing Vials

Check the label for single or multiple use designation

By Elizabeth Hanink, RN, BSN, PHN
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Misuse of single-dose and multiple-use vials is a common and potentially deadly mistake that can trigger outbreaks of blood-borne infections including hepatitis B and C, meningitis and epidural abscesses. There have been enough of these incidents to prompt The Joint Commission to issue a sentinel alert warning healthcare practitioners of the dangers.

“Single-Use” Means Single-Use

The most common error is the reuse of single-dose vials that are intended to be used once for a single patient during one  procedure. Single-use vials are often reused due to limited supplies or concerns about cost and waste, but this practice can have dangerous consequences.

The problem is that single-dose vials lack preservatives and therefore carry a significant risk of bacterial contamination and growth. The CDC has documented multiple incidents in which reuse of these vials has led to infections requiring costly prolonged treatment and follow-up care, not to mention significant legal liability for the hospital involved. Even vials designed for multiple uses can be misused, which also increases the risk of infection or outbreak.

Dos and Don’ts

The Joint Commission has issued the following recommendations for single-dose vials:

  • Use each vial, each needle and each syringe only once. Discard all three after each procedure.
  • Multiple entries = multiple needles. Even if you have to reenter a single-use vial during a single procedure with one patient, be sure to change needles and syringes each time.
  • Don’t combine leftovers. At-tempting to combine leftover medication from several open vials can compound the risk of infection.

For multiple-dose vials:

  • Don’t reuse a vial unless it’s clearly labeled as multiple-use. Regardless of the size of the vial, don’t assume it’s safe for multiple uses unless the manufacturer has so indicated. Read the label!
  • Limit each vial to a single patient as much as possible. However, even with a single patient, you should always use a new needle and new syringe for each entry.
  • Apply aseptic technique. Scrub the rubber septum with an approved antiseptic wash and allow it to dry.
  • Label the open vial with an expiration date.  Unless the manufacturer indicates otherwise, assume the vial expires 28 days from the date of opening.

The Joint Commission also strongly encourages hospitals to initiate supervision and education efforts to counter this unnecessary threat to patient safety.  

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