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Patient Notification for Bloodborne Pathogen Testing due to Unsafe Injection Practices in the US Health Care Settings, 2001–2011

Guh, Alice Y., MD, MPH*; Thompson, Nicola D., PhD; Schaefer, Melissa K., MD*; Patel, Priti R., MD, MPH*; Perz, Joseph F., DrPH*

doi: 10.1097/MLR.0b013e31825517d4
Brief Report

Background: Syringe reuse and other unsafe injection practices can expose patients to bloodborne pathogens (eg, hepatitis B and C viruses and human immunodeficiency virus). Evidence of such infection control lapses has resulted in patient notifications, but the scope and magnitude of these events have not been well characterized.

Objectives: To summarize patient notification events resulting from unsafe injection practices in the US health care settings.

Methods: We examined records of events that involved communications to groups of patients, conducted during 2001–2011, advising bloodborne pathogen testing stemming from potential exposures to unsafe injection practices.

Results: We identified 35 patient notification events related to unsafe injection practices in at least 17 states, resulting in an estimated total of 130,198 patients notified. Among the identified notification events, 83% involved outpatient settings and 74% occurred since 2007, including the 4 largest events (>5000 patients per event). The primary breach identified (≥16 events; 44%) was syringe reuse to access shared medications (eg, single-dose or multidose vials). Twenty-two (63%) notifications stemmed from the identification of viral hepatitis transmission, whereas 13 (37%) were prompted by the discovery of unsafe injection practices, absent evidence of bloodborne pathogen transmission.

Conclusions: Unsafe injection practices represent a form of medical error that have manifested as large-scale adverse events, affecting thousands of patients in a wide variety of health care settings. Our findings suggest that increased oversight and attention to basic infection control are needed to maintain patient safety, along with research to identify best practices for triggering and managing patient notifications.

Divisions of *Healthcare Quality Promotion

Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA

The authors declare no conflict of interest.

Reprints: Alice Y. Guh, MD, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, MS A-31, Atlanta, GA 30030. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.