infection control & hospital epidemiology july 2018, vol. 39, no. 7 original article
Barriers and Facilitators to Injection Safety in Ambulatory Care Settings
Claire Leback, RN, BSN;1 Diep Hoang Johnson, BS;2 Laura Anderson, RN, BSN, MPH;2 Kelli Rogers, MPH;2 Daniel Shirley, MD, MS;3 Nasia Safdar, MD, PhD3,4
objective. Identify factors referred to as barriers and facilitators that can prevent or assist safe injection practices in ambulatory care settings to guide quality improvement.
design. In this mixed-methods study, we utilized observations and interviews.
setting. This study was conducted at ambulatory clinics at a midwestern academic medical center from May through August 2017. Sites included a variety of clinical settings that performed intramuscular, intradermal, intravenous, or intra-articular injections.
participants and interventions. Direct observations of injections and interviews of ambulatory care staff were conducted. An observation checklist was created, including standards of injection safety from nationally recognized guidelines. Interview questions were developed using the System Engineering Initiative for Patient Safety (SEIPS) model. Interviews were recorded, transcribed, and then coded by 2 investigators.
results. In total, 106 observations and 36 interviews were completed at 21 clinics. Injection safety standards with the lowest adherence included using needleless access devices to prepare injections (33%) and the proper use of multidose vials (<80%). Of 819 coded interview segments, 461 (56.3%) were considered facilitators of safe injection practices. The most commonly identified barriers were patient movement during administration, feeling rushed, and inadequate staffing. The most commonly identified facilitators were availability of supplies, experience in the practice area, and availability of safety needles and prefilled syringes.
conclusions. Perceived barriers and facilitators to infection control elements of injection safety are interconnected with SEIPS elements of persons, organizations, technologies, tasks, and environment. Direct observations demonstrated that knowledge of safety injection standards does not necessarily translate to best practices and may not match self-reported data.
Infect Control Hosp Epidemiol 2018;39:841–848
Unsafe injection practices place both patients and healthcare workers (HCWs) at risk for infection transmission. For patients, the vast majority of recent infectious outbreaks in healthcare have occurred in the outpatient setting as the result of unsafe injection practices.1 More than half of these out- breaks involved bloodborne viral or bacterial infections and have not been restricted to a single type of clinic or specialty.1–4 During a 2007 outbreak in Nevada, the reuse of syringes and the use of single-dose vials (SDVs) for multiple patients resulted in up to 106 cases of healthcare-acquired hepatitis C and the notification of 63,000 patients for possible exposure of hepatitis C and other bloodborne pathogens.5,6 Since 2001, >150,000 people have been notified of exposure to bloodborne infections in similar outbreak investigations. These incidents prompted The Joint Commission (TJC) to release a Sentinel Event Alert calling for the improvement of injection practices.7
Safe injection practices also protectHCWs from exposure to bloodborne pathogens. The Centers for Disease Control and Prevention (CDC) defines a sharp injury as “a penetrating stab wound from a needle, scalpel, or other sharp object that may result in exposure to blood or other body fluid.” The CDC estimates that 385,000 sharps-related injuries occur annually in hospital settings; however, it is also estimated that 50% of sharp injuries go unreported.8 Most needlestick injuries occur in the inpatient setting, but almost 10% occur in ambulatory settings.9 Among the 150 ambulatory clinics in the current study, the incidence of sharps injuries has increased since 2015, and more than half have been from needle sticks (unpublished internal communication). Safe medication administration is a national patient safety
goal for ambulatory healthcare.10 To promote safe medical injection practices, the CDC launched “The One & Only
Affiliations: 1. University of Wisconsin, Madison, Wisconsin; 2. University of Wisconsin Health, Madison, Wisconsin; 3. Division of Infection Disease,
Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; 4. William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin.
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0011. DOI: 10.1017/ice.2018.82 Received November 17, 2017; accepted March 2, 2018
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