1. Shastay, Ann MSN, RN, AOCN

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According to the Centers for Disease Control and Prevention (CDC), unsafe injection practices have affected more than 150,000 patients since 2001, including more than 50 documented outbreaks of viral hepatitis or bacterial infections (2017). Although many practitioners follow the CDC safe injection practices guideline, a survey of more than 5,000 practitioners about the use of needles, syringes, and vials suggests that some may be placing patients at risk for transmission of bloodborne diseases (Pugliese et al., 2010). For example, 1% of the survey respondents admitted to sometimes or always reusing a syringe for more than one patient.


We first learned about the unsafe practice of reusing a prefilled saline flush syringe from a 2013 press release issued by a New York hospital that was investigating possible disease transmission in 236 patients hospitalized during a 3-month period (Guthrie Health, 2013). In that case, a single nurse had been reusing prefilled saline syringes to flush the intravenous (IV) lines of multiple patients, mistakenly believing that the practice was safe. Luckily, no cases of disease transmission had been identified at the time of the press release.


More recently, the March 10, 2017, issue of Morbidity and Mortality Weekly Report described a very similar event, this time in a Texas hospital. A nurse who worked in a telemetry unit had been reusing prefilled saline syringes to flush the lines of multiple patients, which led to a case of hepatitis C transmission (Arnold et al., 2017). The unsafe practice was discovered after noticing that the nurse would often leave a partially filled saline flush syringe near a computer workstation. When a nurse manager investigated this practice, the nurse voluntarily reported reusing syringes during the previous 6 months, believing it was cost-effective and safe if no fluids had been withdrawn into the syringe prior to injecting the saline. The nurse had been working on the unit for 18 months but had not been taught that this was an unsafe practice.


Because all telemetry unit patients were required to have IV access, all 392 living patients potentially exposed to this unsafe practice were notified about the possible exposure to bloodborne diseases and the need for laboratory testing. One of two patients who tested positive for hepatitis C had been admitted to the unit during the same time as a patient with known preexisting chronic hepatitis C infection. Genotyping and molecular sequencing identified that both were infected with an identical strain, which accounts for only about 1% of all hepatitis C infections in the United States. The CDC concluded that at least one of the hepatitis C infections was likely transmitted as a result of inappropriate reuse and sharing of the saline flushes between multiple patients (Arnold et al., 2017).


ISMP is concerned that reports of the reuse of prefilled saline flush syringes are signals of more widespread unsafe practices that illustrate the need for ongoing education and improved monitoring. Given the potential for harm associated with this unsafe practice, several opportunities exist to reduce the risk of errors.



Provide initial orientation and annual education on injection safety and include new and temporary nurses. Assess and reinforce practitioner competence associated with even the most basic concepts of infection control and aseptic technique, including recognition that any form of syringe and/or needle reuse is dangerous and should be prohibited.


Policies and Procedures

Review organizational policies and procedures related to safe injection practices to ensure that the principles of infection control, aseptic technique, the CDC safe injection practices guideline (Siegel et al., 2007), and the ISMP Safe Practice Guidelines for Adult IV Push Medications (Institute for Safe Medication Practices, 2015) have been incorporated.



It is essential to monitor adherence with proper injection techniques in all settings where medications are prepared and administered. Consider developing a checklist (ASC Quality Collaboration, 2017) based on the CDC safe injection practices guideline (Siegel et al., 2007) that can be used to conduct the surveillance process and collect the data. Syringe reuse, if identified, should be immediately corrected, and patients should always be notified of any potential exposures and the need for testing (Arnold et al., 2017).


Dispense a Needle With That Pen

A diabetic patient visited an endocrinologist at an academic medical center, where she was prescribed HUMULIN R (insulin regular concentrate) U-500 pens. The patient was to administer 140 units 3 times a day. The prescription was dispensed by the medical center's ambulatory pharmacy, where the patient was given the pens but no pen needles. As she didn't have any needles for the pens, when she got home she used one of her U-100 syringes that she had used with her previous U-100 insulin to draw her insulin dose from the U-500 insulin pen cartridge (essentially using the pen as a vial). It's possible that she may have measured and administered as much as "140" units (700 units of U-500). Her daughter found her unresponsive and called for an ambulance. When emergency medical technicians arrived, they gave the patient 12.5 g of 50% dextrose and transported her to the hospital, where she fully recovered.


Similarly, in our June 16, 2016 issue, we described a patient who was previously using insulin glargine U-100 but switched to TOUJEO (insulin glargine U-300). In this case, he was given pen needles to use with Toujeo, but at home, he decided to use up the remaining supply of U-100 syringes. Using the insulin pen cartridge as a vial, he drew up a dose, filling the U-100 syringe to the 100-unit mark-the same daily Lantus dose (100 units) he had been taking. This resulted in a dose of 300 units of Toujeo, not the prescribed 100 units, which led to hypoglycemia requiring hospital admission.


Plans are underway at the medical center where the most recent error was reported to give pharmacists authority to dispense pen needles without a prescription whenever insulin pens are prescribed. Perhaps insurance providers who currently require a prescription for needles should take note and allow pharmacists to dispense appropriate pen needles whenever a pen device has been prescribed. Also, it is critical for prescribers, nurses, and pharmacists to educate patients about the proper use of insulin pen devices, the importance of using the correct pen needle with the device, and to never use the insulin pen cartridge as a vial. In addition, a process should be in place prior to discharge to ensure that patients have the medications or prescriptions, equipment, and supplies needed at home to manage their insulin therapy (e.g., insulin, syringes or pen needles, blood glucose meter and strips, lancets, lancing device, glucagon emergency kit).




Arnold S., Melville S. K., Morehead B., Vaughan G., Moorman A., Crist M. B. (2017). Notes from the field: Hepatitis C transmission from inappropriate reuse of saline flush syringes for multiple patients in an acute care general hospital-Texas, 2015. Morbidity and Mortality Weekly Report (MMWR), 66(9), 258-260. [Context Link]


ASC Quality Collaboration. (2017). Safe injection practices toolkit. [Context Link]


Centers for Disease Control and Prevention. (2017). The One & Only Campaign.


Guthrie Health. (2013). Guthrie Corning Hospital alerts patients to possible saline flush syringe reuse. [Context Link]


Institute for Safe Medication Practices. (2015). ISMP safe practice guidelines for adult IV push medications. [Context Link]


Pugliese G., Gosnell C., Bartley J. M., Robinson S. (2010). Injection practices among clinicians in United States health care settings. American Journal of Infection Control, 38(10), 789-798. [Context Link]


Siegel J. D., Rhinehart E., Jackson M., Chiarello L.Healthcare Infection Control Practices Advisory Committee. (2007). Safe injection practices to prevent transmission of infections to patients. In: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta: US Department of Health and Human Services. [Context Link]