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Safe Injection Practices

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Learning Objectives

  • Recommended procedures
  • Risk of reusing vials
  • Risk of reusing syringes

Course Description

Nearly all caregivers who deliver injections believe their technique is proper and safe. It isn’t so. In June 2014, the Joint Commission issued a Sentinel Event Alert raising the alarm about ongoing findings that unsafe injection practices are widespread, resulting in intolerable harm to patients. The Joint Commission Alert followed a survey of 5446 healthcare practitioners in which those surveyed self-reported that:

  • 15% used the same syringe to re-enter multidose vials for the same patient
  • 6% sometimes or always use single-dose vials for multiple patients
  • 1.1% reported saving those reused vials for other patients
  • 1% sometimes or always reuse a syringe on a second patient after changing the needle

Infection caused by unsafe injection practices is a Never Event. It is entirely preventable and should never occur. The key to safe injections is education and uncompromising adherence to published guidelines and recommended procedures.

“In the last 5 years, the CDC is aware of at least 26 outbreaks due to unsafe injection practices. These outbreaks resulted in more than 95,000 patients being referred after potential exposure to infectious diseases.” — Centers for Disease Control, Injection Safety, 2017


Amplifire evaluated 160 caregivers (mostly RNs) in the Duke Infection Control Outreach Network (DICON) on the topic of safe injection practices. Amplifire assesses not only knowledge, but confidence—are you sure you are correct? The questions in this pilot were thoroughly vetted by DICON clinicians before the course was rolled out.

The caregivers knew with confidence only 42% of the material. They were uncertain about 33%. And they were confident and wrong about 25%.

Confidence is important because it drives decisions. Confidently held misinformation (CHM) increases the risk of error and the potential for infection outbreaks.

With Amplifire, clinicians can quickly assess their knowledge and fix misinformation in brisk, low-cost learning sessions. At the end of an Amplifire session, heat maps document the starting knowledge of the practitioner—and the attainment of mastery by the end of the session.

Author Information

Course development guided by the expertise of Daniel J. Sexton, MD, FIDSA, FSHEA Director, Duke Infection Control Outreach Network (DICON)

Dr. Sexton is a Professor of Medicine at Duke University, whose research focuses on healthcare-acquired infections (HAIs). Using data collected by the Duke Infection Control Outreach Network (DICON), Dr. Sexton and his colleagues have focused on the following areas of research:

  • The accuracy and reliability of surveillance definitions used to document and trend rates of HAIs
  • Outcomes of HAIs (both financial and clinical) with particular emphasis on bloodstream and surgical site infections
  • Trends in HAIs due to pathogens resistant to common antimicrobial agents
  • Temporal and geographic variations in the occurrence of pathogens such as methicillin-resistant S. aureus, E. coli and Klebsiella pneumoniae
  • The prevention and control of HAIs with particular emphasis on the potential role of the environment in the transmission of HAIs

Did You Know...

  • There have been at least 50 major outbreaks due to unsafe injection practices since 2001
  • Hundreds have been harmed and some killed
  • Over 150,000 patients required notification to undergo testing because of potential exposure
  • A study by CDC and CMS found that 66% of certified surgical centers had lapses in basic infection control

Course at a Glance

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time to complete icon Time to Complete:

35 Minutes

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