Safe Injection Guidelines for Needle and Syringe Use

Standard IX of the American Association of Nurse Anesthetists (AANA) Standards for Nurse Anesthesia Practice states that Certified Registered Nurse Anesthetists (CRNAs) shall take precautions “to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.”1 Further, the AANA Code of Ethics for the Certified Registered Nurse Anesthetist states that every AANA member “has a personal responsibility to uphold and adhere”2 to the ethical standards contained therein.  Specifically, Code of Ethics 3.2 states that the “CRNA practices in accordance with the professional practice standards established by the profession.”2  The AANA has historically taken a strong position concerning infection control and the AANA Infection Control Guide for Certified Registered Nurse Anesthetists3 has served as a valuable resource to CRNAs for many years.
Despite attempts to educate healthcare providers regarding the public hazards of syringe and needle reuse and other unsafe injection practices, transmission of bloodborne pathogens continues to occur in the United States.4-7 Within the years 1998 to 2008, there were 33 significant outbreaks involving transmission of the Hepatitis B or C viruses due to unsafe injection practices.5 These outbreaks placed over 60,000 patients at risk for contracting bloodborne infections.5
Successful prevention of the transmission of infectious agents involves adherence to best practices by the anesthesia professional. These guidelines address aspects of anesthesia care which involve the use of needles and syringes when administering injectable medications.
The following statements reflect current safe practices for needle and syringe use by CRNAs:
  • Never administer medications from the same syringe to multiple patients, even if the needle is changed. 8, 9
  • Never reuse a needle, 6, 10-12 or needleless access device even on the same patient.  Once a needle or access device has been used, it is considered contaminated and must be discarded in an appropriately identified sharps container.  Access devices are single-use devices.6, 8
  • Never refill a syringe once it has been used, even for the same patient.  Syringes are single-use devices.3, 6, 11-13 Once the plunger of a syringe has been completely depressed in order to expel the syringe contents (i.e., intravenous medication), the internal barrel of the syringe is considered contaminated and must be discarded in an appropriate fashion.  A syringe must only be used once to draw up medication, and must not be used again even to draw up the same medication from the same vial for the same patient.13-16 CRNAs should weigh the risks of possible syringe contamination (e.g., from anesthesia workspace contamination17-20) that may occur when repeatedly connecting and disconnecting a medication-filled syringe from an intravenous infusion set or other administration systems.
  • Never use infusion or intravenous administration sets on more than one patient.8 Infusion and intravenous sets are single-patient use items and must be used according to applicable policies and guidelines.  These devices are to be used on one patient only, and must never be used between patients.
  • Never reuse a syringe or needle to withdraw medication from a multidose vial (MDV).6, 21 A new sterile syringe and needle or access device are required each time an MDV is accessed.8, 11, 22  Practitioners should avoid using MDVs if at all possible.11, 23  If MDV must be used, the practitioner should consider using that MDV on only one patient.9, 12  Although MDVs contain a preservative, they still may become contaminated with infectious agents due to unsafe practices.  Do not access an MDV in the immediate patient treatment area unless the MDV is dedicated to a single patient and discarded immediately thereafter.8,24
  • Never reenter a single-dose medication vial, ampoule or intravenous infusion bag.9, 21, 24, 25 It is not appropriate to prepare multiple intravenous flush syringes for single or multiple patients from the same single-use intravenous solution bag or bottle (e.g., normal saline).6, 12, 26 It is not appropriate to prepare multiple fentanyl, midazolam, or propofol syringes for the same or multiple patients from the same single-use medication vial, ampoule, or solution. Do not store a single-use medication vial for future use. Do not reenter a single-use medication vial, even for the same patient
CRNAs have an ethical obligation to deliver care to minimize risk of infection for their patients or themselves. Syringes and needles are single-use items that must only be used once.  These guidelines were written in accordance with best practices to enhance patient safety and minimize healthcare costs.27
  1. Standards for Nurse Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthetists; 2013.
  2. Code of Ethics for the Certified Registered Nurse Anesthetist. Park Ridge, IL: American Association of Nurse Anesthetists; 2010.
  3. Infection Control Guide for Certified Registered Nurse Anesthetists. Park Ridge, IL: American Association of Nurse Anesthetists; 2012.
  4. Wilson WO. Infection control issue: understanding and addressing the prevalence of unsafe injection practices in healthcare. AANA J. Aug 2008;76(4):251-253.
  5. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. Jan 6 2009;150(1):33-39.
  6. CDC's Position - Protect Patients Against Preventable Harm from Improper Use of Single-dose⁄Single-use Vials. 2012; Accessed February 21, 2014.
  7. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. Dec 2010;38(10):789-798.
  8. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. Dec 2007;35(10 Suppl 2):S65-164.
  9. Fischer GE, Schaefer MK, Labus BJ, et al. Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008. Clin Infect Dis. Aug 1 2010;51(3):267-273.
  10. King CA, Ogg M. Safe injection practices for administration of propofol. AORN J. Mar 2012;95(3):365-372.
  11. Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of hepatitis C virus during myocardial perfusion imaging in an outpatient clinic. Am J Cardiol. Jul 1 2011;108(1):126-132.
  12. Dolan SA, Felizardo G, Barnes S, et al. APIC position paper: safe injection, infusion, and medication vial practices in health care. Am J Infect Control. Apr 2010;38(3):167-172.
  13. Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak investigations highlight the need for safe injection practices and basic infection control. Clin Liver Dis. Feb 2010;14(1):137-151; x.
  14. Perceval A. Consequence of syringe-plunger contamination. Med J Aust. May 17 1980;1(10):487-489.
  15. Huey WY, Newton DW, Augustine SC, Vejraska BD, Mitrano FP. Microbial contamination potential of sterile disposable plastic syringes. Am J Hosp Pharm. Jan 1985;42(1):102-105.
  16. Olivier LC, Kendoff D, Wolfhard U, Nast-Kolb D, Nazif Yazici M, Esche H. Modified syringe design prevents plunger-related contamination--results of contamination and flow-rate tests. J Hosp Infect. Feb 2003;53(2):140-143.
  17. Baillie JK, Sultan P, Graveling E, Forrest C, Lafong C. Contamination of anaesthetic machines with pathogenic organisms. Anaesthesia. Dec 2007;62(12):1257-1261.
  18. Jeske HC, Tiefenthaler W, Hohlrieder M, Hinterberger G, Benzer A. Bacterial contamination of anaesthetists' hands by personal mobile phone and fixed phone use in the operating theatre. Anaesthesia. Sep 2007;62(9):904-906.
  19. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. Sep 2008;109(3):399-407.
  20. Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg. Jan 2011;112(1):98-105.
  21. Branch-Elliman W, Weiss D, Balter S, Bornschlegel K, Phillips M. Hepatitis C transmission due to contamination of multidose medication vials: Summary of an outbreak and a call to action. Am J Infect Control. May 25 2012.
  22. Arrington ME, Gabbert KC, Mazgaj PW, Wolf MT. Multidose vial contamination in anesthesia. AANA J. Dec 1990;58(6):462-466.
  23. Rehan HS, Chopra D, Sah RK, Chawla T, Agarwal A, Sharma GK. Injection practices of healthcare professionals in a Tertiary Care Hospital. J Infect Public Health. Apr 2012;5(2):177-181.
  24. Silberzweig JE, Khorsandi AS, Dixon RG, Gross K, Nikolic B. Society of Interventional Radiology position statement on injection safety: improper use of single-dose/single-use vials. J. Vasc. Interv. Radiol. Jan 2013;24(1):111-112.
  25. Infection control requirements for dialysis facilities and clarification regarding guidance on parenteral medication vials. MMWR Morb Mortal Wkly Rep. Aug 15 2008;57(32):875-876.
  26. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control. Oct 2011;39(8):663-670.
  27. Ford K. Survey of syringe and needle safety among student registered nurse anesthetists: are we making any progress? AANA J. Feb 2013;81(1):37-42.  

In January 2009, the AANA Board of Directors adopted  Position Statement 2.13, Safe Practices for Needle and Syringe Use. This position statement was reaffirmed by the AANA Board of Directors in November 2012. In April 2014, the AANA Board of Directors archived this position statement and adopted the Safe Injection Guidelines for Needle and Syringe Use.
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