What are the guidelines for safe injection practices?

Safe Injection Practices

All healthcare providers must use sterile, disposable needles and syringes for each injection, never reusing or sharing equipment between patients, and must dispose of used sharps immediately in puncture-proof containers without recapping. 1

Core Infection Control Principles

Hand Hygiene and Glove Use

• Hands must be washed with soap and water or cleansed with alcohol-based waterless antiseptic hand rub between each patient contact 1
• Gloves are not required when administering injections unless the provider is likely to come into contact with potentially infectious body fluids or has open lesions on their hands 1

Sterile Technique Requirements

• Syringes and needles used for injections must be sterile and disposable to minimize the risk of contamination 1
• A separate needle and syringe must be used for each injection 1
• Changing needles between drawing vaccine from a vial and injecting it into a recipient is unnecessary 1
• Different vaccines should never be mixed in the same syringe unless specifically licensed for such use 1

Vial Access and Medication Preparation

• Wipe the rubber membrane of medication vials with an alcohol swab before accessing 2
• Never reenter single-use medication vials to prepare doses for multiple patients 3
• When using multidose vials, never reuse a syringe or needle to withdraw medication 3
• Use only sterile (e.g., boiled) water to prepare drugs; if not possible, use clean water from a reliable source 1

Proper Injection Technique

Subcutaneous Injections

• Administer at a 45-degree angle into the thigh of infants aged <12 months and in the upper-outer triceps area of persons aged >12 months 1
• Use a 5/8-inch, 23-25 gauge needle inserted into the subcutaneous tissue 1, 4
• Subcutaneous injections can be administered into the upper-outer triceps area of an infant if necessary 1

Intramuscular Injections

• Administer at a 90-degree angle into the anterolateral aspect of the thigh or the deltoid muscle of the upper arm 1
• The buttock should never be used for administration of vaccines or medications because of the potential risk of injury to the sciatic nerve and decreased immunogenicity of certain vaccines (hepatitis B and rabies) in adults 1, 5, 4
• For adolescents and adults, use the deltoid muscle as the preferred site, with the anterolateral thigh as an alternative 5
• Use a 22-25 gauge needle, 1-1½ inches in length for adolescents to ensure proper muscle penetration 5
• The needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone 1

Injection Site Preparation and Technique

• Clean the injection site with a new alcohol swab before injection 1
• Allow alcohol to dry completely before vaccine administration to prevent potential inactivation of live vaccines 6
• Aspiration (pulling back the syringe plunger before injection) is not necessary, as no data exist to document the necessity for this procedure 1
• Keep the needle under the skin for at least 6 seconds to ensure complete medication delivery 2
• If blood appears after withdrawing the needle, press the injection site lightly with a finger; do not rub the area 2

Critical Safety Measures to Prevent Disease Transmission

Needle and Syringe Reuse Prevention

• Never reuse or share syringes, needles, water, or drug preparation equipment 1
• Never administer medications from the same syringe to multiple patients 3
• Never reuse a needle on the same patient 3
• Never refill used syringes 3
• Never reuse infusion sets for more than one patient 3

Sharps Disposal

• Disposable needles and syringes must be discarded in labeled, puncture-proof containers immediately after use to prevent inadvertent needle-stick injury or reuse 1
• Never recap needles after use 2
• Used syringes, needles, or lancets should be placed in sharps containers (such as red biohazard containers), hard plastic containers (such as detergent bottles), or metal containers (such as an empty coffee can) 2
• Such containers should be sealed and disposed of properly 2
• Safety needles or needle-free injection devices should be used whenever available to reduce the risk for injury 1

Special Considerations for Injection Drug Users

For patients who continue to inject drugs despite counseling to stop, provide the following harm reduction guidance:

• Use only sterile syringes obtained from a reliable source (e.g., pharmacies or syringe exchange programs) 1
• Use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs 1
• If injection equipment that has been used by other persons is shared, first clean the equipment with bleach and water 1
• Safely dispose of syringes after one use 1

Common Pitfalls to Avoid

Critical violations that continue to occur despite clear guidelines:

• Approximately 4% of student anesthesia providers have administered medications from the same syringe to multiple patients 3
• 18% have reused a needle on the same patient 3
• 82% have refilled used syringes 3
• 22% have reused a syringe or needle to withdraw medication from a multidose vial 3
• 49% have reentered a single-use medication vial to prepare doses for multiple patients 3

These practices must be completely eliminated through education and supervision, as they pose serious risks for transmission of bloodborne pathogens including HIV, hepatitis B, and hepatitis C. 3, 7