Sentinel Event Alert 52, issued on 6/16/14, focuses our attention on the risk of prevention that can occur when appropriate infection prevention methods are not observed in the use of both single (e.g., haloperidol lactate, Geodon), and multi-dose (e.g., Lantus, Fluphenazine decanoate) vials. According to the alert, the most common misuse of vials involves reusing single-dose vials.  Staff may not appreciate the fact that single-dose vials usually “lack antimicrobial preservatives and are therefore at greater risk to become contaminated” and become the source of bacterial infections,  hepatitis B or C. The entire SEA 52 is provided in this article and it includes specific recommendations for infection prevention when using single and/or multi-dose vials. A concise summary of these recommendations is available in a related article of the Perspectives on Patient Safety column of this months The Source, Page 19, entitled, ‘Joint Commission Releases Sentinel Event Alert on Misuse of Vials’. Perhaps the most important thing for staff to remember is the concept and slogan from the CDC’s ‘One & Only Campaign’ of ONE Needle, ONE Syringe ONLY ONE time. See also CMS S&C:12-35-All (Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections )
Tip1: Make sure your hospital conducts regular inspections for open vials on all clinical units.  Consider incorporating this into your infection/environmental safety rounds.
Tip2: Take advantage of 2 related tools (MDV Expiration Calendars 2014/2015 and Sentinel Event Response Form – SEAR) provided courtesy of Central Louisiana State Hospital (CLSH) and see the ‘Comments’ section of this article for a listing of some commonly used MDV/SDV medications in psychiatric hospitals, more links/resources for the ‘One & Only Campaign’.