Giving Safe Injections - WHO

Giving safe injectionsA guide for nurses andothers who give injectionsWorld Health OrganizationInternational Council of Nurses

The World Health Organization (WHO) defines asafe injection to be one that does not harm therecipient, does not harm the health careworker, and does not harm the community

Needles, syringes and other skin-piercingmedical devices can harm: The patient when unsterile devices are reused andtransmit disease The health care worker when they suffer needlesticks that can cause disease The community when the public can pick up andreuse syringes or when unsafe burning causesharmful emissions

Outline: How to give injections safely Eliminate unnecessary injectionsUse sterile injection equipment and sharpsPrepare and give injections without contaminationDispose of sharps to prevent reuse and harmfulwaste

Eliminate unnecessary injections becauseinjections may be dangerousInjections can: Spread hepatitis B virus, hepatitis C virus, HIVand other pathogens Cause nerve and other tissue damage, which canlead to paralysis Cause abscesses and injuries

Most injections are unnecessary A safer and equally effectivedrug may exist that can begiven to the patient bymouth, through the skin orby rectum

Eliminate injectionsthat do not help the patient Injectable vitamins,tranquilizers, antibiotics andsteroids are often givenwithout a good medicalreason

It is unethical to give injections only tomake money Raise money for salaries orclinic by activities that donot harm patients nor wastemedications

Outline: How to give injections safely Eliminate unnecessary injections Use sterile injection equipment and sharps Prepare and give injections without causingcontamination or needle-sticks Dispose of sharps to prevent reuse and harmfulwaste

Poor injection practices in the worldUnnecessaryinjectionsReuse of syringeswithout sterilizationMillions of cases of hepatitis B, Cand other bloodborne diseases

Reuse of injection equipment isdangerous and common Reuse of non-sterile syringes and needles spread:––––HBVHCVHIVOther bloodborne pathogens Do not give injections unlesssterile equipment is availableReuse of injectionequipmentin South Asia

Assume needles and syringesare sterile if: Disposable, single use needles and syringes:– Are purchased from a reliable manufacturer and are inindividual, undamaged and unopened packaging Sterilizable injection equipment:––––IsIsIsIscleaned before sterilizationprocessed in a sterilizer monitored with indicatorssterilized under routine supervisiondesigned to be re-usable

Discard packages if punctured, torn ordamaged by moisture Damaged packages are notsterile since germs or toxinscan contaminate injectionequipment if the outerpackage is damagedCheck each packagefor tears or damage

Use a sterile syringe and a sterile needleto mix each vial of medication and diluent It is not safe to change theneedle but reuse the syringe Do not use the same mixingsyringe to reconstituteseveral vials

Use a sterile syringe and sterile needle forevery injection Open the package in frontof patients to reassure themthat the syringe and needlehave not been used before

If disposable syringes and needles are notavailable, sterilize equipment Only sterilize equipment designed for reuse Disposable equipment, especially narrow needles,cannot be sterilized safely with steam

What is “sterilization” ? “Sterilization” refers to thesteps that reduce thenumber of organisms on anitem to a safe level Boiling in an open pan,soaking syringes andneedles in alcohol ordisinfectants does not“sterilize” and is not safe

Steam sterilization requires: Water, brushes and gloves to clean syringes andneedles of all visible dirt before sterilization Use of indicators Storage of sterile syringes and needles in a dry,sealed container A system of routine supervision

Sterilization must be monitored byindicators and supervisors Indicators for steamsterilization show ifconditions of time, steampressure and temperature(TST) have been met TST spots are recommendedfor immunizationprogrammesTST spotindicators

Auto-Disable (AD) syringes prevent reuse AD syringes disablethemselves after one use They have a fixed dose andare currently used inimmunization and familyplanning programmes They prevent reuse, but notneedle-sticksAD syringe

Outline: How to give injections safely Eliminate unnecessary injections Use sterile injection equipment and sharps Prepare and give injections without causingcontamination or needle-sticks Dispose of sharps to prevent reuse and harmfulwaste

Prepare injections in a clean,designated area Do not allow blood,specimens or contaminatedsupplies supplies in thisspace Keep the area free of clutterso all surfaces can be easilycleaned and disinfected

Wash hands under running water Wash hands with soap ordisinfect with waterlessalcohol solutions beforepreparing or givinginjections Wash hands again aftercontact with soil, blood, orbody fluids

Follow manufacturers’ instructions for thestorage and use of each medication Some medications must be:– Discarded after openingsince they have nopreservativesOR– Kept between 2-8 º COR– Reconstituted only with aspecific diluent

Use single-dose vials rather than multidose vials, if possible Multi-dose vials have beenlinked to many outbreaks If syringes are reused withmulti-dose vials the entirevial will be contaminatedand can cause illness ordeath

Use a sterile syringe and needle to withdrawa dose and inject with the same needle Never leave a needle in thevial. A needle left in theseptum opens the vial tocontamination

Discard medication vials withcracks, leaks or visible contamination While deadly contaminationmay be invisible, visiblecontamination or cracks inthe vial indicate that the vialshould not be used When in doubt:– Throw it out

Discard needles that touch hands,surfaces or non-sterile objects Surfaces and hands containmicrobes (germs) Sterile devices become nonsterile if touched

Swabbing the tops of vials or ampouleswith a disinfectant is unnecessary Never store cotton wet indisinfectant. All disinfectantscan become contaminatedand spread disease If vials are swabbed, useindividually packagedisopropyl alcohol, or ethanol- Never methanol

Swabbing the skin prior to injectionis unnecessary Clean visibly dirty skin withclean water and dry withclean cotton If skin is swabbed, use anindividually packaged swabof isopropyl alcohol orethanol DANGER!– Most cleaning agents andother alcohols (methanol ormethyl-alcohol) are notsafe for human use

Do not open glass ampouleswith bare fingers Staff often cut their fingerswhen opening glassampoules Bleeding fingerscontaminate vials, syringesand the work setting

Protect fingers from cuts when openingampoules Use clean pliers, two smallhinges, clamps made fromclean bent bottle caps, rigidpieces of plastic or a carvedpiece of woodWhile rigid materials protectfingers better, a piece ofgauze may offer someprotection

During injections, prevent sudden patientmovements that may cause needle-sticks Many needle-sticks occur when children or adultsmove unexpectedly. Restrain children gently andsecurely in the lap of an adult with arms and legsheld Assess the mental condition of bed-ridden patientsand ask a co-worker to help restrain adult patientswho may be confused

Do not recap needles Recapping commonly leadsto needle-sticks If recapping is necessary,use a one-handed technique

Gloves are not usually needed whengiving injections Disposable gloves may beused to give injections ifexcessive bleeding isexpectedGloves

How to give injections safely: Outline Eliminate unnecessary injections Use sterile injection equipment and sharps Prepare and give injections without contamination orneedle-sticks Dispose of sharps to prevent reuse and harmfulwaste

After use, immediately put syringes andneedles in a puncture-proof sharpscontainer Keep a safety box where theinjections are given Do not store used sharps inan open container wherethey can be reused or causeneedle-sticks when dumped

Close safety boxes when they are 3/4 fulland lock boxes in a secure area Seal boxes to preventpersons from removingneedles to reuse them.Locked storage may beneeded if persons sell usedsyringes. Needle-sticks can occur ifboxes are overfilled

Know how syringes are stored anddestroyed at your facility– Tour your facility to see if used injection equipment isvisible in public areas– Know how and where used syringes are stored– Find out how syringes are destroyed at your facility– Used sharps in the environment is a sign that the medicalwaste handling needs to be improvedHealth carewaste in theenvironment in AfricaUse of anincinerator inCentral Asia

Unfortunately, managing waste in an efficient,safe and environment-friendly way is not easy Without efforts to keepsyringes separated fromroutine waste, syringes canappear on the clinic groundsand lead to reuse andneedle-sticks Facilities with incineratorsneed supervision, skilledstaff and procedures toencourage safemanagement

Technical information on medical wastedisposal is available from WHOwww.healthcarewaste.org

These recommended techniques shouldbe applied only to ID, SC and IMinjections Different recommendations, including those for skinpreparation and use of gloves, exist for:– Intravenous administration of medication and fluids– Blood cultures– Needle-free injections

For more information.The SIGN SecretariatWorld Health OrganizationDepartment of Blood Safetyand Clinical TechnologyAvenue Appia, 201211 Geneva,SwitzerlandEmail: sign@who.intwww.injectionsafety.org

make money Raise money for salaries or clinic by activities that do not harm patients nor waste medications. Outline: How to give injections safely Eliminate unnecessary injections Use sterile injection equipment and sharps Prepare and give injections without causing