IV. Standard Precautions

D. Injection Safety

Injection safety refers to the proper use and handling of supplies for administering injections and infusions (e.g., syringes, needles, fingerstick devices, intravenous tubing, medication vials, and parenteral solutions). These practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare personnel during preparation and administration of parenteral medications.

To the extent possible, medication preparation should take place in pharmacy settings and dedicated medication rooms. All staff personnel who use or handle parenteral medications and related supplies should be aware of labeling and storage requirements and pharmacy standards. Additional recommendations for safe injection practices, including the appropriate use of single-dose (or single-use) and multi-dose vials and the proper technique for accessing intravascular devices, can be found in Section IV.E. (Medication Storage and Handling), in Section VI (Central Venous Catheters), respectively, as well as in Appendix D.

1.  General Safe Injection Practices

• Use aseptic technique when preparing and administering chemotherapy infusions or other parenteral medications (e.g., antiemetics, diphenhydramine, dexamethasone)
• Whenever possible, use commercially manufactured or pharmacy-prepared prefilled syringes (e.g., saline and heparin)
• Avoid prefilling and storing batch-prepared syringes except in accordance with pharmacy standards
• Avoid unwrapping syringes prior to the time of use
• Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing
• Do not reuse a syringe to enter a medication vial or solution
• Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient (e.g, do not use a bag of saline as a common source supply for multiple patients)
• Cleanse the access diaphragms of medication vials with 70% alcohol and allow the alcohol to dry before inserting a device into the vial
• Dedicate multi-dose vials to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they are restricted to a dedicated medication preparation area and should not enter the immediate patient treatment area (e.g., exam room, chemotherapy suite)
• Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof
• Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient
• Use single-use, disposable fingerstick devices (e.g., lancets) to obtain samples for checking a patient’s blood glucose, PT/INR, etc. and dispose of them after each use; do not use a lancet holder or penlet device for this purpose
• Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens

2.   Spinal Injection Procedures

• Use aseptic technique and follow safe injection practices (e.g., dedicating single-dose vials to single-patient use)
• At a minimum, wear a facemask (e.g., procedure or surgical masks) and sterile gloves when injecting material or inserting a catheter into the epidural or subdural space (e.g., administration of intrathecal chemotherapy)
• For other spinal procedures (e.g., diagnostic and therapeutic lumbar punctures) or handling of devices to access the cerebrospinal fluid (e.g., Ommaya reservoir):
  • At a minimum, use aseptic technique and follow safe injection practices
  • Facemask can be considered as an additional precaution

3.  Phlebotomy Procedures

• Phlebotomy procedures are performed in a dedicated area, if possible
• If the procedure has to be done elsewhere (e.g., exam room, chemotherapy suite), do not bring common trays of supplies for phlebotomy or intravenous device access to the patient’s immediate treatment area; bring only the necessary supplies to the patient side
• Hand hygiene stations (e.g., alcohol-based hand rub dispensers) are readily accessible to the phlebotomist
• Use aseptic technique to perform the phlebotomy procedure
• Do not reuse vacutainer holders
• Sharps containers are strategically placed near the phlebotomist to ensure easy access and safe disposal of used supplies
• Minimize environmental contamination by performing the following:
  • Label tubes before blood is drawn
  • Avoid placing tubes on patient charts or other items or surfaces that cannot be properly cleaned
  • Do not process or store blood specimens near medications or medication preparation area

CDC  Clinical Reminder: Spinal Injection Procedures Performed without a Facemaks Pose Risk for Baterial Meningitis [PDF - 548 KB]

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E. Medication Storage and Handling

The measures outlined in this section pertain to the general storage and handling of parenteral medications outside of the pharmacy setting. The appropriate storage and handling (e.g., reconstituting, mixing, diluting, compounding) of antineoplastic drugs and other sterile medications that typically require preparation in pharmacy settings should be determined in accordance with established official and enforceable standards for these activities (e.g., ensuring appropriate environmental and engineering controls such as biological safety cabinets and laminar airflow hoods, and proper use of aseptic technique), including those of the United States Pharmacopeia and the Food and Drug Administration. These functions are performed by personnel who have the appropriate qualifications and training as determined in accordance with the state pharmacy board.  Consultation with the state pharmacy board and oncology pharmacy specialists is recommended.

In general, parenteral medication storage, handling, and administration should adhere to injection safety measures as outlined in Section IV.D. (Injection Safety). Parenteral medications include single-dose and multi-dose vials, ampoules, bags or bottles of intravenous fluids.

Single-dose vials (or single-use vials) are intended for use in a single patient for a single case/procedure/injection. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

Multi-dose vials contain more than one dose of medication. They are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. However, this preservative has no effect on viruses and does not fully protect against contamination when safe injection practices are not followed.

1.  Medication Storage

• Store all medications (e.g., injectable hormonal agents) in accordance with manufacturer’s instructions (e.g., shelf-life, temperature)
• Use of freezers/refrigerators
  • Store medications that require refrigeration in a dedicated, labeled refrigerator that meets requirements for such storage (e.g., thermostat control, separate exterior door for refrigerator and freezer compartments)
  • Designated personnel maintain temperature log (monitor temperature at least twice daily for vaccine storage) and ensure alternative storage method is in place in the event of power or refrigerator failure
• Multi-dose vials are stored in the Medication Room and not in the immediate patient treatment area (e.g., exam room, chemotherapy suite)

2.  Medication Preparation

• Draw up medications in the Medication Room or in a designated clean area that is free of any items potentially contaminated with blood or body fluids (e.g., used equipment such as syringes, needles, IV tubing, blood collection tubes, and needle holders)
• Note: Multi-dose vials should not be accessed in the immediate patient treatment area (e.g., exam room, chemotherapy suite); if a multi-dose vial enters the immediate patient-care area, it should be dedicated to that patient and discarded after use
• Note: Bags or bottles of intravenous solution (e.g., bag of saline) should not be used for more than one patient
• Use an aseptic technique to access parenteral medications:
  • Perform hand hygiene before handling the medication
  • Disinfect the rubber septum with alcohol and allow the alcohol to dry prior to piercing
  • Always use a new sterile syringe and sterile needle to draw up the medication; be careful to avoid contact with the non-sterile environment during the process
  • Never leave a needle inserted into the septum of a medication vial for multiple draws
  • Ensure that any device inserted into the septum (e.g., chemotherapy dispensing pins) are used in accordance with manufacturer’s instructions and they do not compromise the integrity of the remaining vial contents
  • Minimize multiple entries into bags of fluid to add medications; if more than one entry is required, always use a new sterile syringe and sterile needle and access the bag using aseptic technique

3.  When to Discard Medications

• Medications should always be discarded according to the manufacture’s expiration date (even if not opened) and whenever sterility is compromised or questionable
• For single-dose vials that have been opened or accessed (e.g., needle-puncture), the vial should be discarded according to the time the manufacturer specifies for the opened vial or at the end of the case/procedure for which it is being used, whichever comes first. It should not be stored for future use.
• For multidose vials that have been opened or accessed (e.g., needle-punctured), the vials should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial

CDC 2007 Guideline for Isolation Precautions

CDC FAQs Regarding Safe Practices for Medical Injections

CDC Vaccine Storage and Handling Toolkit

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F. Cleaning and Disinfection of Devices and Environmental Surfaces

The procedures outlined in this section pertain to the cleaning and disinfection of noncritical patient-care devices (e.g., blood pressure cuff) and environmental surfaces in patient-care areas (e.g., exam rooms) and certain common-use areas (e.g., bathrooms).

Standard procedures and recommended practices for cleaning and disinfecting compounding areas (e.g., pharmacy settings) and the handling, transporting, and disposing of antineoplastic agents should be determined in accordance with local, state, and federal authorities, including state board of pharmacy, USP, FDA, and DEA.

1.  Designated Personnel

• Responsibilities for cleaning and disinfection of environmental surfaces and medical equipment are assigned to specific personnel (as indicated in Appendix B)
  • If Environmental Services are only available after-hours (e.g., contractors from outside agency), then designated facility staff are assigned specific responsibilities for cleaning and disinfection during clinic hours
• All assigned personnel are trained in the appropriate cleaning/disinfection procedures and the proper use of PPE and cleaning products

2.  Supplies and Cleaning Products

• Designated personnel regularly restock necessary supplies (e.g., gloves, gowns, facemasks) and replenish dispensers of alcohol-based hand rub and soap throughout the facility
• Follow manufacturer’s instructions for cleaning surfaces and noncritical devices; ensure that the cleaning product used is compatible with the surface/device being cleaned
• Use EPA-registered disinfectant with appropriate germicidal claim for the infective agent of concern (may vary depending on situation) and follow the manufacturer’s safety precautions and instructions (e.g., amount, dilution, safe use, storage and disposal) for cleaning/disinfection
• Products and supplies are reviewed periodically (e.g., annually) due to product developments and improvements and to ensure that the materials used are consistent with existing guidelines and meet the needs of the staff
• If reusable mops and cleaning cloths are used, these are cleaned after use and allowed to dry before reuse

3.  Frequency of Cleaning

Patient-care areas, medication preparation areas (outside pharmacy/compounding areas), and bathrooms are cleaned at least daily, with the following exceptions:

• Promptly clean and decontaminate any location with spills of blood and other potentially infectious materials (refer to step 7 below)
• Clean medication preparation areas when visibly soiled; if medication preparation takes place in the patient treatment area (outside a designated medication room), clean this area after each patient encounter:
  • Ensure the medication preparation area is free of any items contaminated with blood or body fluids (e.g., used equipment such as syringes, needles, IV tubing, blood collection tubes, and needle holders)
• Disinfect bathrooms after use by a patient with known or suspected infectious diarrhea and before use by another person (refer to step 5 below)
• Disinfect environmental surfaces and noncritical patient-care devices when visibly soiled
• Disinfect environmental surfaces and noncritical patient-care devices in between patient use if:
  • There was direct contact to non-intact skin or mucous membrane or potential contamination with body fluids (e.g., blood, secretions)
  • The patient-care device involves a blood glucose meter or other point of care testing device (e.g., PT/INR readers) that utilizes blood samples; to prevent bloodborne pathogen transmission, these devices must be cleaned and disinfected after each use in accordance with manufacturer’s instructions

4.  Cleaning Patient-Care Areas

General cleaning and disinfection measures that apply to any patient-care area:

• Wear appropriate PPE
• In general, cleaning should be performed before disinfection unless a one-step detergent disinfectant is used
• Wet-dust horizontal surfaces by moistening a cloth with a small amount of an EPA-registered disinfectant
• Avoid dusting methods that disperse dust (e.g., feather-dusting)
• Concentrate on cleaning high-touch surfaces (areas frequently touched by patients and facility staff) and those in close proximity to the patient, as outlined below for specific rooms/areas
• Follow manufacturer’s instructions for cleaning and maintaining noncritical medical device/equipment
• Clean walls, blinds, and window curtains when they are visibly dusty or soiled

Cleaning and disinfection measures for specific patient-care areas:

Exam Rooms

• Change the paper covering the exam table and pillows between patient use
• Place any used linens (e.g., exam gowns, sheets) in a designated container located in each exam room after each patient use; refer to step 8 below for laundering soiled linens
• Clean any medication preparation area after each patient encounter and ensure contaminated items (as described above) are not placed in or near the area
• Focus cleaning on high-touch surfaces (at least daily), e.g., exam bed, bedrails, blood pressure cuff, stethoscope, wall-mounted ophthalmoscope and otoscope (per manufacturer’s instructions), chair and bedside stool, and door knob
• Decontaminate high-touch surfaces using an EPA-registered disinfectant with specific claim labels for the infective agent
  • If patient has suspected infectious diarrhea and the infective agent is unknown, clean high-touch surfaces using a sodium hypochlorite (bleach)-based product (e.g., 1:10 dilution prepared fresh)

Chemotherapy Suites

• Clean patient chair, IV poles/pumps, and side table between each patient use
• Clean any medication preparation area after each patient encounter and ensure contaminated items (as described above) are not placed in or near the area

Triage Stations and/or Locations for Performing Vital Signs (if not done in exam rooms)

• Focus cleaning on high-touch surfaces (at least daily): patient chair, blood pressure cuff, pulse oximetry sensors (follow manufacturer’s instructions), thermometers (if disposable oral temperature probes are used, they should be discarded after each use)

Phlebotomy Stations

• Focus cleaning on high-touch surfaces (at least daily): patient chair and arm rest, procedure table
• Promptly clean and disinfect surfaces contaminated by blood using an EPA-registered disinfectant with specific label claims for bloodborne pathogens (e.g, HIV, HBV, HCV); refer to step 7 for cleaning spills of blood

5.  Cleaning Bathrooms

• Wear appropriate PPE
• Clean the toilet, the area around the toilet, the sink, and faucet handles at least daily, and the walls if visibly soiled
• If used by a patient with known or suspected infectious diarrhea, clean the bathroom before it is used again, focusing on the toilet and the area around the toilet:
  • Use an EPA-registered disinfectant with specific claim labels for the infective agent 
  • If infective agent is unknown, use a bleach-based disinfectant (e.g., 1:10 dilution prepared fresh)

6.  Cleaning Medication Rooms (excluding pharmacy settings or locations where sterile compounding is performed; for these locations, refer to the state pharmacy board and USP recommendations)

• Wear appropriate PPE
• Clean the countertops and surfaces where medication preparation occurs at least daily and when visibly soiled
• Ensure contaminated items (as described above) are not placed in or near the medication preparation area
• Refrigerators for storing medications are cleaned at defined intervals and when soiled, in accordance with manufacturer’s instructions

7.  Cleaning Spills of Blood and Body Substances

• Wear protective gloves and use appropriate PPE (e.g., use forceps to pick up any sharps and discard in sharps container)
• If the spill contains large amounts of blood or body fluids (e.g., >10 mL), clean the visible matter with disposable absorbent material and discard in appropriate containers for biohazardous waste
• Decontaminate the area using an EPA-registered disinfectant with specific label claims for bloodborne pathogens (e.g., HIV, HBV, HCV) or a freshly diluted bleach-based product (preferably EPA-registered), in accordance with manufacturer’s instructions, and allow the surface to dry
• If a bleach-based product is used:
  • Use a 1:100 dilution to decontaminate nonporous surfaces
  • If the spill involves large amounts of blood or body fluids, use a 1:10 dilution for first application of germicide before cleaning, then followed by cleaning and subsequent decontamination with 1:100 dilution application

8.  Handling and Laundering Soiled Linens

• Handle all contaminated linens with minimum agitation to avoid contamination of air, surfaces, and persons
• Do not sort or rinse soiled linens in patient-care areas
• Use leak-resistant containment for linens contaminated with blood or body substances; ensure that there is not leakage during transport
• If laundry chutes are used, ensure that laundry bags are closed before tossing the filled bag into the chute; do not place loose items in the laundry chute
• In the laundry area, appropriate PPE (e.g., gloves) are worn by laundry personnel while sorting soiled linen, and hand hygiene supplies are available for their use
• If laundry equipment is available on premise, use and maintain the equipment according to manufacturer’s instructions
  • In general, If hot-water laundry cycles are used, wash with detergent in water ≥160°F (≥71°C) for ≥25 minutes
  • If low-temperature (<160°F [<70°C ]) laundry cycles are used, wash with proper concentrations of laundry chemicals that are suitable for low-temperature washing
• If commercial laundry facilities are used, ensure that their laundering process is in accordance with current recommendations

9.  Waste Disposal

• Puncture-resistant, leak-proof sharps containers are located in every patient-care area (e.g., exam room, chemotherapy suite, phlebotomy station)
  • Specifically for phlebotomy stations, a sharps container is located within a short distance of each phlebotomist’s work space
  • All sharps are disposed of in the designated sharps container; do not bend, recap, or break used syringe needles before discarding them into the container
  • Filled sharps containers are disposed of in accordance with state regulated medical waste rules
• Regular trash and regulated medical waste (e.g., biohazardous material and chemical hazardous waste, including antineoplastic drugs) are disposed of in their designated containers
• All trash and waste containers are emptied at least daily by designated personnel
  • Wear appropriate PPE
  • Handle, transport, and dispose regulated waste, including antineoplastic and hazardous drugs, in accordance with state and local regulations

CDC Guidelines for Environmental Infection Control in Health-Care Facilities [PDF - 1.4 MB]

CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

CDC Guideline for the Prevention and Control of Norovirus Gastroenteritis Outberaks in Healthcare Settings

CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration

 APIC Infection Prevention Manual for Ambulatory Care, 2009

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