633 Patient Notification for Bloodborne Pathogen Testing Due to Unsafe Injection Practices in U.S. Healthcare Settings, 19992009

Saturday, March 20, 2010
Grand Hall (Hyatt Regency Atlanta)
Alice Y. Guh, MD, MPH , CDC, Atlanta, GA
Nicola D. Thompson, PhD , CDC, Atlanta, GA
Melissa K. Schaefer, MD , CDC, Atlanta, GA
Joseph F. Perz, DrPH , CDC, Atlanta, GA

Reuse of syringes and other unsafe injection practices can potentially expose patients to bloodborne pathogens (BBP) such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Evidence of such infection control lapses has resulted in a number of large patient notifications, but the scope and magnitude of these events have not been well characterized.   


To review and summarize patient notifications that were prompted by evidence of unsafe injection practices during the preparation and administration of parenteral medications in U.S. healthcare settings.  


Patient notification was defined as a written communication (i.e., letter) addressed to a group of patients advising BBP testing because of their increased risk of exposure to bloodborne infections during a healthcare procedure. We reviewed published and unpublished reports of patient notifications associated with unsafe injection practices in U.S. healthcare settings during 1999–2009; descriptive frequencies were examined. Notifications that were prompted by improper reprocessing of medical equipment (e.g., endoscopes) or other infection control breaches were excluded.


We identified 23 patient notification events related to healthcare delivery in 14 states. The estimated total number of patients notified was 129,517 and the median number of patients notified per event was 1851 (range: 36–53,000). The majority of notifications (n=15; 65%) occurred since 2007, including 6 of the 7 largest notifications (>5000 patients per notification). Most of the identified notifications (n=18; 78%) were associated with the delivery of healthcare in non-hospital settings, including physician offices and specialty clinics. Fourteen (61%) of 23 notification events were prompted by evidence stemming from investigation of BBP transmission (HBV or HCV), either as a result of patient-to-patient transmission (n=12), or from an infected provider to a patient as a result of narcotics diversion (n=2). Nine (39%) notifications were prompted by the recognition of unsafe injection practices in the absence of documented BBP transmission.


In recent years, patient notification events resulting from unsafe injection practices appear to have grown in frequency and magnitude. Increased oversight and greater attention to basic infection control is needed to prevent these events and maintain basic patient protections. These findings also underscore the importance of identifying best practices for conducting patient notifications.