Flashpoint Details

July 20, 2012

CDC: Improper Injection Practices Result in Life-Threatening Outbreaks


On July 13, the Centers for Disease Control (CDC) released a report detailing two life-threatening infections that occurred when health care providers used medication from single-dose/single-use vials for multiple patients undergoing pain treatment. As a result, at least 10 patients contracted severe staphylococcus or methicillin-resistant Staphylococcus aureus (MRSA) infections that required hospitalizations. An additional patient died, possibly of MRSA.

These breaches of basic infection control practices are a stark reminder that the CDC recommendations for injection safety must be followed closely with every patient, even if there is a medication shortage. When individually packaged and appropriately-sized single-dose/single-use vials are unavailable, contents from unopened vials can be packaged in multiple single-use vehicles, provided that the repackaging is performed in accordance with all standards in the United States Pharmacopeia General Chapter .

The CDC encourages all clinicians to double check their practices against CDC’s Injection Safety Recommendations. A checklist is available on the CDC website. In addition, CDC offers health care providers a toolkit  featuring a narrated PowerPoint presentation that is ideal for Staff meetings, seminars, and other educational opportunities.

The full report is available on the CDC website.

For additional questions, contact Carol Wagner, Senior Vice President Patient Safety at (206) 577-1831 or carolw@wsha.org.


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