safe injection and hazards of unsafe injection

1. FAMILY PRACTICE PEARLS
SAFE INJECTION PRACTICE
DR. KAMLESH LALA
M.B.B.S.; D.PED, FCGP
FAMILY PHYSICIAN
NARANPURA AND SHAHIBAG
KAMLESHLALA@HOTMAIL.COM

2. HISTORY
 Invention of syringes date back to 1848.
 It opened a new channel for blood borne diseases
 The first recorded outbreak (Later on identified as Hepatitis B) occurred in 1883 following
smallpox vaccination.
 In 1943, Bigger and MacCalum showed that non sterile injections transmitted a pathogen
that caused jaundice..
 Disposable syringes came in 1950.

3. MAGNITUDE OF INJECTION PRACTICE
• Most common percutaneous health care procedure
• India contributes to ~30% of the 16 billion injections administered worldwide
per year.
• Average number of health care injection per person was estimated to be 3.7
per year
• More than 95% injections are given for therapeutic purposes
• 5% are given for preventive services including immunization and family
planning.
• Majority of them are unnecessary (90%) and unsafe (50%)
• 63% of injections in India are estimated to be unsafe and nearly 27% of these
are due to re-use.

4. Source: WHO South-East Asia Journal of Public Health 2012;1(2):189-200.

5. IS GIVING AN INJECTION NECESSARY ??
According to WHO use injections only when necessary – oral medicines are
effective in most cases.
Indications for therapeutic injections are
1. Severe and life threatening illness
2. Inability to swallow
3. Profuse vomiting
4. Non availability of effective oral agent
5. Significantly altered absorption pattern
6. The issue of onset of action is clinically relevant only in life threatening
illness

6. WHEN INJECTIONS ARE MEDICALLY
INDICATED : THEY SHOULD BE SAFE
According to WHO definition:
Safe injection
1. Does not harm the recipient
2. Does not expose the provider to any avoidable risk
3. Does not result in waste that is dangerous for the community

7. WHAT MAKES INJECTION UNSAFE
• Unnecessary use of injection
• Needle stick injuries
• Unsafe sharp waste management
• Re-use of needle and syringe
• Recycling of used equipment

8. In India,
this problem is complex and multifactorial
due to
• The lack of awareness,
• Social commitment
• Lack of availability of sufficient resources in health
care settings.

9. THE FIRST SAFE INJECTION INITIATIVE BEGAN
ALMOST MORE THAN 100 YEARS AGO.

10. RISKS:
• Unsafe injections place recipients and provider at risk of disease, disability and death.
• Can cause injuries and toxicities when wrong injection site, drug, diluent or dose is used.
• The risk of transmission of infection after injury with contaminated sharps is:
1. 1:3 workers for HBV
2. 1:30 for HCV
3. 1:300 for HIV
• HBV persists for up to seven days on surfaces.

11. RISKS:
Apart from HBV, HCV and HIV transmission, other complications are:
1. Transmission of other viral, bacterial, fungal or parasitic infections
2. Vaso vagal shock
3. Drug toxicities including Anaphylaxis
4. Injection abscess and infections
5. Nerve injury

12. MAGNITUDE
An assessment of injection practices in India found that nearly one third of
all injections carried a potential risk of transmitting a blood borne
pathogen.
It is important to note that symptoms of HBV and HCV sometimes do not
appear and risks are unappreciated until ten or more years after infection,
so many more patients may have been infected but are not yet aware of
their condition.

16. WHAT IS INJECTION SAFETY?
Injection safety includes
practices intended to prevent transmission of infectious diseases
• Between one patient and another
• Between a patient and health care provider
• Prevent harms such as needle stick injuries

17. SAFE INJECTION PRACTICES INVOLVE
• Universal precautions irrespective of infectivity of patient and
assuming all body fluids infectious.
• Use of sterile single-use needles and syringes for each procedure.
• Prevention of any form of contamination to the medication or
vaccine to be injected.
• Prevention of sharps injuries and
• Appropriate waste disposal to prevent reuse of needles and
syringes.

18. CHARACTERISTICS OF UNSAFE INJECTIONS
(63% of all injections are unsafe – All India)
CAUSE Percentage
Wrong Habits of Injection Givers 54%
Questionable Sterility 24%
Reuse 22%

19. PRACTICES THAT CAN HARM RECIPIENTS
(SELECTION OF EQUIPMENT)
• Involves issues like sterilization, storage and handling
• Reusing syringe or needle
for giving injection, for reconstitution of medication,
or withdrawal from a multidose vial
• Improper selection of length and bore of needle
• Changing the needle but reusing the syringe.

20. PRACTICES THAT CAN HARM RECIPIENTS
(STERILIZATION ISSUES)
• Sterilization without supervision or monitoring with time, steam and temperature
indicators.
• Attempting to sterilize and reuse syringe.
• Attempting to sterilize injection equipment without prior cleaning.
• Boiling injection equipment in an open pan. (Still done by dentists)
• Using only disinfectant on contaminated equipment to prepare them for reuse.

21. PRACTICES THAT CAN HARM RECIPIENTS
(MEDICATION PREPARATION ISSUES)
• May be
• Before Opening
• During Opening
• After Opening

22. PRACTICES THAT CAN HARM RECIPIENTS
(MEDICATION PREPARATION ISSUES)
Before Opening
• Unsafe environment
• Error in selection of type of medication
• Not checking medication vial label and expiry date
• Wiping the stopper with antiseptics (Use only spirit and allow it to
dry)
• Medication should be drawn up in a designated clean area.
• Do not reconstitute it till the person to be immunized is ready

23. PRACTICES THAT CAN HARM RECIPIENTS
(MEDICATION PREPARATION ISSUES)
During Opening
• Use of Incorrect diluent. (Diluents are vaccine specific)
• Use of incorrect quantity of diluent.
• Carelessly breaking the ampoule so as to injure oneself.
• Mixing two partially opened vials of same vaccine.
• Loading syringe with multiple doses and injecting multiple persons.
• Mixing more than one medications in the same syringe.
• WHEN IN DOUBT, THROW IT OUT

24. PRACTICES THAT CAN HARM RECIPIENTS
(MEDICATION PREPARATION ISSUES)
After Opening
• Keeping freeze dried vaccines more than six hours after reconstitution.
• Leaving a needle in the vial to withdraw additional doses.
• Handling of Multidose vial (use new needle every time even if it has not been
used)
• Opened vial submerged in water.

25. PRACTICES THAT CAN HARM RECIPIENTS
(MEDICATION PREPARATION ISSUES)
• Not following product specific recommendations for use, storage and
handling, especially vaccines.
• Single dose vial used for multiple patients.
• Multidose vial when punctured, should be discarded within 28 days.
• Always consider IV tubing, syringe and other components as a single inter
connected unit.
• Even if no blood is seen in IV tubing or syringe, they are always considered
as contaminated.

26. INTRAMUSCULAR INJECTIONS
Nearly 24 potentially critical steps in giving an injection have
been formulated by steering group of WHO and has drawn
an evidence based guidelines to make injection safer

27. INTRAMUSCULAR INJECTIONS
1. Environment (clean designated area)
2. Preparation of Injection
Equipment, Needle size, Air bubble, Wiping the needle
2. Position
3. Proper hand washing and Site preparation (cleansing)
4. Technique
5. Measures to alleviate discomfort and pain
6. Procedure: Insertion of needle, aspiration, pushing the medication
7. Withdrawal of syringe
8. Multiple injections
9. Post injection (Applying pressure to bleeding site with cotton or finger)

29. PRACTICES THAT CAN HARM RECIPIENTS
(PATIENT)
• Giving vaccines in buttocks.
• Giving injection to infants in gluteal region
• Touching needle with finger while injecting (Use as a support)
• Dividing the dose of same vaccine.

30. PRACTICES THAT CAN HARM RECIPIENTS
(SOMETHING UNUSUAL)
I have seen the ward boy in one so called multi specialty hospital
injecting the patient and taking sutures.
1. Mixing tetanus toxoid and diclofenac in the same syringe.
2. Tetanus toxoid was not stored in refrigerator.
3. Giving that injection in gluteal region. (Vaccines are never ever to
be given in gluteal region).
4. Took a previously used skin stapler lying in the open tray and took
sutures.
Just see how many issues have been compromised???

31. PRACTICES THAT CAN HARM HCW
OUR MAIN AIM IS TO PREVENT SHARP INJURIES

32. PRACTICES THAT CAN HARM HCW
OUR MAIN AIM IS TO PREVENT SHARP INJURIES
Magnitude of Sharp Injury (Needle Stick Injury-NSI):
Considering it on an individual basis, according to WHO, it ranges from
0.93 to 4.68 injuries per person per year in developing countries as
against only 0.18 to 0.74 in developed countries.
Majority of sharp injuries occur between completing the procedure
and disposing of the device.

33. NEEDLE STICK INJURIES
According to a study by the trauma center of AIIMS, Delhi
Doctors were found to have the highest exposure to needle stick injuries
(36.2%),
followed by nurses (14.6%) and
hospital waste disposal staff (7.6%)

34. PRACTICES THAT CAN HARM HCW
OUR MAIN AIM IS TO PREVENT SHARP INJURIES
• Skin integrity is compromised by local infection or weeping dermatitis.
(cover any small cut with water proof adhesives or wear gloves)
• Moving around with a filled or used syringe in the hand.
• Accidental injury while giving injection (Beware of unusual and abrupt movement
by a child or patient)

35. PRACTICES THAT CAN HARM HCW
OUR MAIN AIM IS TO PREVENT SHARP INJURIES
• Trying to recap, bend or manually remove the needle from the syringe after use.
• Reaching into a mass of used equipment (For cleaning or sorting waste)
• Sharp container is kept at a distance from place of procedure.
• Quality and standard of sharps container.

36. NEEDLE STICK INJURY
• Do not accept it as a part of job.
• The risks can be drastically reduced by 84-100% through IEC, safer
working place and using newer technology.
• Minimum handling of injection equipment is key to preventing
sharp injuries.
• Use of Needle cutter and burner has been made mandatory by law.

37. NEEDLE STICK INJURY
DO’S AND DON’S AFTER NSI

38. PRACTICES THAT CAN HARM THE
COMMUNITY

39. PRACTICES THAT CAN HARM THE COMMUNITY
(PROBLEMS BEYOND CONTROL)
• Discarding and dumping used injections in public places by
drug users.
• Home injections for diabetes, cancer, AIDS, osteoporosis etc.
• SMBG by diabetics

40. PRACTICES THAT CAN HARM THE COMMUNITY
(OTHER PROBLEMS BEYOND CONTROL)

42. DO’S AND DON’TS
DURING DISPOSAL OF NEEDLES AND
OTHER SHARPS USED AT HOME,
AT WORK, OR WHILE TRAVELING

43. DO’S AND DON’TS
DO’S
• Immediately place used needles and other sharps in a sharps disposal container
• Keep all needles and other sharps and sharps disposal containers out of reach of
children and pets
• Be prepared — carry a portable sharps disposal container for travel.

44. DO’S AND DON’TS
DON’T throw loose needles and other sharps into the trash.
DON’T flush needles and other sharps down the toilet.
DON’T put needles and other sharps in your recycling bin -- they
are not recyclable.
DON’T try to remove, bend, break, or recap needles used by
another person.

46. SHARPS CONTAINERS
All sharps disposal containers should be:
• made of a heavy-duty plastic
• able to close with a tight-fitting, puncture-proof lid, without sharps being able to
come out
• upright and stable during use
• leak-resistant
• properly labeled.

47. Priced at Rs. 2000/= Priced at only Rs. 60/= only
small, portable, bedside, economic

48. Be assure to manage home sharps waste
in an efficient, safe and
environmental friendly way.

49. WHAT TO DO
IF NO SAFETY BOX IS AVAILABLE
If safety boxes are not available,
• Strong cardboard boxes, metal cans or thick plastic containers may be used.
• Collect needles and syringes and transport them to a site where they can be
properly treated (buried, incinerated or autoclaved and shredded).
• Containers should be sealed when they are three-quarters full.
• They should not be reused once filled.
• Do not try to empty sharps containers for reuse

55. REUSE OF SYRINGES
May be Downstream Re-use or Intentional Re-use
Downstream Reuse –
After not properly discarding the syringes by the injection giver,
someone else takes it for reuse.
• Improper Disposal
• Picked up by rag pickers
• Sold to scrap dealers
• Cleaned, Disinfected(?), Repacked
• Resale in the market

56. REUSE OF SYRINGES
Intentional Re-use
Injection giver intentionally brings about reuse of the syringe
• Lack of knowledge, education and awareness.
• Ignorance and misconception
• Altruism- disinterested and selfless concern for the well being of others
• Lack of resources and corruption
• Monitory gain
"Most healthcare workers who do reuse syringes are really decent people,
but the system forces them to."

57. PREVENTING RE-USE
In February 2015, the WHO issued a policy that urged all
nations to switch to the use of "smart" single-use syringes
by 2020. These are syringes that are specifically engineered
to prevent their re-use.

58. PREVENTING RE-USE
In India needle cutting and/or burning is made compulsory
by law. It can be manual or electrical and available for
anything between Rs. 200 to 2000.

59. WHO RECOMMENDED INJECTION
TECHNOLOGY
Newer technologies help professionals immensely in their endeavor towards
safe injection practice. It prevents both downstream and intentional reuse.
1. Auto Disable AD syringe
2. Re use prevention RUP syringe
3. Prefilled injection devices.
4. Safety syringes with retractable needles
5. Vacuum based technology for blood collection

60. WHO RECOMMENDED INJECTION
TECHNOLOGY
Auto-disable syringes:
Auto-disable (AD) syringes automatically become disabled after one use.
After the plunger is depressed past the point of safety, it cannot be
pulled backwards for reuse. These are in use across the globe post a joint
endorsement by WHO, UNICEF and UNFPA.

61. WHO RECOMMENDED INJECTION
TECHNOLOGY
Re-use preventive syringes (RUP):
RUP is mechanically similar to the AD syringe. RUP syringes are
disposable syringes with self-locking mechanisms that allow only one
use.

62. WHO RECOMMENDED INJECTION
TECHNOLOGY
SYRINGE WITH RETRACTABLE NEEDLE
The needle automatically retracts into the syringe and plunger rod,
allowing safe and compact disposal.

63. WHO RECOMMENDED INJECTION
TECHNOLOGY
SIP + RUP retractable syringes:
Once the plunger is fully pressed, the plunger mechanism locks into the
needle unit. When the plunger is pulled back, the needle also gets pulled
back into the syringe barrel, enclosing the used needle. The needle shield
protects others from accidental needle sticks and prevents reuse of the
syringe.