The Joint Commission this week issued a new Sentinel Event Alert calling attention to the misuse of single-dose/single-use and multiple-dose vials. This has adversely affected thousands of patients, including outbreaks of bloodborne pathogens and associated infections including hepatitis B and C, meningitis, and epidural abscesses.

The alert said misuse of vials primarily involves the reuse of single-dose vials, which are intended to be used once for a single patient. Single-dose vials usually lack preservatives and thus, using them more than once carries risks for bacterial contamination, growth, and infection.

Read the Sentinel Event Alert here.