Unsafe Injections Put Patients in Peril

Far from a healthy shot in the arm, some injections carry more than medicine into the veins and bodies of patients.

To date, more than 150,000 people have received letters after going to outpatient centers and other health care providers notifying them they were potentially exposed to unsafe injection practices, and, as a result, diseases such as hepatitis C, an infection of the liver that commonly becomes chronic, as well as bacterial infections. That's according to the latest figures from the Centers for Disease Control and Prevention, which began keeping statistics on the problem in 2001.

Through 2011, the most recent year for which data are available, dangerously negligent practices such as reusing single-use syringes or drawing from single-use medication vials to administer injections to multiple individuals have led to more than 40 outbreaks nationwide.

Health officials say the findings punctuate a need to raise awareness and improve safety education among providers and patients in the U.S.

"I think it was realizing that this was not just a developing world problem," says CDC health care epidemiologist Dr. Joseph Perz. "CDC was supporting the World Health Organization, and its Safe Injection Global Network activities -- that's something that CDC helped found in the late 1990s -- and what we realized by the early 2000s is that we had a lot more outbreak activity here in the U.S. than we'd anticipated."

Perz and his CDC colleagues say problems persist today.

Earlier this month, Tonya Rushing, the former chief operating officer of a Las Vegas medical clinic involved in a 2007 hepatitis C outbreak tied to unsafe injection practices, pleaded guilty to conspiracy to commit health care fraud for inflated billing practices and received a sentence of one year and one day in federal prison. Rushing had served under the physician owner of the Endoscopy Center of Southern Nevada, Dr. Dipak Kantila Desai.

For his part, Dr. Desai is serving a life sentence for second-degree murder, related to the death of a 77-year-old patient infected with hepatitis C.

"What made this outbreak different is that this wasn't just a bad day. It was the routine practice in the clinic," Perz says. Nurse anesthetists, who also faced prosecution in the case, were found to have routinely reused syringes, against proper single-use protocol, repeatedly dipping into vials containing the sedative propofol, which were apparently contaminated with hepatitis C. Perz called the outbreak a "tipping point" for stepped-up efforts to raise public awareness about unsafe infection practices.

While the CDC says most providers follow safe injection practices, he and others at the agency stress that recent outbreaks highlight the need for patients to remain vigilant. That includes an ongoing investigation into a Santa Barbara, California, doctor's office where unsafe injection practices were implicated in at least five patients testing positive for hepatitis C.

"There's been a lot of real patient harm -- life-threatening diseases, not limited to but including hepatitis C, multiple-drug resistant staph aureus, a long list of fairly serious infections," Perz says. Among them: HIV and spinal meningitis.

One unsafe injection practice that gets less recognition, he says, involves a health provider's failure to wear a face mask -- as they should -- while administering a spinal injection.

"That is a way of spreading bacteria to one of your protected, sterile immune sites, anatomically. You can imagine that if bacteria are inadvertently introduced into your spine that the outcome could be very bad," he says. "There's a number of outbreaks involving spinal meningitis that have occurred from, most likely, the simple failure to wear a face mask as recommended in that situation."

Injecting patients safely also requires keeping up with the times and changing health care technology.

Insulin pens created for convenient use by one individual have been misused in health care settings. "We've had a number of situations -- not outbreaks, per se, but situations -- where somebody in a hospital, a nurse, uses that insulin pen for more than one patient," Perz says. "We've had thousands of patients who've had to get letters and go through the anxiety of testing. We've not documented an outbreak, thank goodness." But, he says, it raises concern as pre-filled, self-injection pens are becoming more prevalent.

"The technology is moving. That's good for patients who are managing their own disease process, but we have to be very careful when that technology is introduced into a health care setting and we don't have all the safeguards and training in place," Perz adds. "So that's something the [CDC] campaign has tried to bring attention to as well."

Outspoken patient advocate Evelyn McKnight, the victim of unsafe injection practices, encourages patients to talk openly with providers about injection safety.

"Certainly when you're going to be given an injection, ask, 'Is this going to be one needle, one syringe, only for me, only used one time?' You might ask to see them open the needle in front of you," she says.

That's central to the CDC's "One & Only" public awareness campaign, which aims to educate providers and patients, and facilitate dialogue on safe injection practices.

"It's a little bit technical for a patient to start to ask providers questions about if they're using a single-dose vial versus a multiple-dose vial, and how much of which, and which equipment that they're using," says campaign director Jennifer Mitchell. "So we try on our website to provide introductory level questions so that patients feel empowered in being able to have this type of conversation if they're concerned about their safety and their environment."

The CDC recommends patients ask health care providers the following questions before receiving an injection:

-- Will a new needle, new syringe and a new vial be used for this procedure or injection?

-- Can you tell me how you prevent the spread of infections in your facility?

-- What steps are you taking to keep me safe?

Mitchell and others want patients to realize these questions are far from an extraneous add-on to health care conversations; rather they fit into broader discussion about infection control that CDC recommends patients routinely have with providers. The agency insists, for example, that patients not be bashful about asking doctors or other providers to wash their hands -- an infection-control measure as powerful as it is simple, and one that studies show frequently gets skipped.

For backup -- and to guide the safe-injection-practices discussion -- Mitchell recommends patients download and print out a health care provider brochure and separate pocket card with injection safety information from the One & Only website and take it with them to share with health care providers.

McKnight says providers should, in turn, be open to having injection safety conversations. She knows all too well the stakes for patients.

In 2001, McKnight contracted hepatitis C while being treated for a recurrence of breast cancer at a clinic in Fremont, Nebraska, where she lives. Under her oncologist's direction, nurses had reused syringes to draw contaminated saline from a vial used for multiple patients, infecting McKnight and 98 patients with hepatitis C in what remains one of the largest health care outbreaks in U.S. history.

"It was such suffering for all of our community," McKnight says. "I mean 99 people. There was such sorrow and grief and difficulty. Lives were lost. Six people died from hepatitis C, not from cancer. It's also completely preventable."

McKnight went on to co-found HONOReform, a public policy organization, along with the nonprofit HONOReform Foundation, focused on developing programs to prevent future outbreaks, like promoting safe injection practices, and she has encouraged the CDC's public awareness efforts.

"I am fortunate: I cleared the virus," says McKnight, who is also cancer free. "I think when you go through a crisis, a trauma like this, the only solace you can take is [that] what happened to us can be used to prevent it from happening to anybody else."