title: Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001-2011.
abstract: 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.
  
  
  OBJECTIVE
  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.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30030, USA. ggt4@cdc.gov
authors.forename: Alice Y
authors.initials: AY
authors.lastname: Guh
authors.forename: Nicola D
authors.initials: ND
authors.lastname: Thompson
authors.forename: Melissa K
authors.initials: MK
authors.lastname: Schaefer
authors.forename: Priti R
authors.initials: PR
authors.lastname: Patel
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Perz
mesh_terms: D017848:Blood-Borne Pathogens; D016358:Contact Tracing / Q000706:statistics & numerical data*; D030881:Disclosure / Q000706:statistics & numerical data; D018563:Disease Notification; D004866:Equipment Contamination; D017743:Equipment Reuse; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data; D018805:Sepsis / Q000453:epidemiology / Q000382:microbiology; D013594:Syringes / Q000009:adverse effects*; D014481:United States