Giving safe injections

A guide for nurses and

others who give injections

World Health Organization

International Council of Nurses
The World Health Organization (WHO) defines a
safe injection to be one that does not harm the
recipient, does not harm the health care
worker, and does not harm the community
Needles, syringes and other skin-piercing
medical devices can harm:
• The patient when unsterile devices are reused and
transmit disease
• The health care worker when they suffer needle-
sticks that can cause disease
• The community when the public can pick up and
reuse syringes or when unsafe burning causes
harmful emissions
 Outline: How to give injections safely

• Eliminate unnecessary injections

• Use sterile injection equipment and sharps
• Prepare and give injections without contamination
• Dispose of sharps to prevent reuse and harmful
waste
Eliminate unnecessary injections because
injections may be dangerous
Injections can:
• Spread hepatitis B virus, hepatitis C virus, HIV
and other pathogens
• Cause nerve and other tissue damage, which can
lead to paralysis
• Cause abscesses and injuries
 Most injections are unnecessary

• A safer and equally effective

drug may exist that can be
given to the patient by
mouth, through the skin or
by rectum
 Eliminate injections
that do not help the patient
• Injectable vitamins,
tranquilizers, antibiotics and
steroids are often given
without a good medical
reason
 It is unethical to give injections only to
make money
• Raise money for salaries or
clinic by activities that do
not harm patients nor waste
medications
 Outline: How to give injections safely

• Eliminate unnecessary injections

• Use sterile injection equipment and sharps
• Prepare and give injections without causing
contamination or needle-sticks
• Dispose of sharps to prevent reuse and harmful
waste
Poor injection practices in the world

Unnecessary Reuse of syringes

injections without sterilization

Millions of cases of hepatitis B, C

and other bloodborne diseases
 Reuse of injection equipment is
dangerous and common
• Reuse of non-sterile syringes and needles spread:
– HBV
– HCV
– HIV
– Other bloodborne pathogens
• Do not give injections unless
sterile equipment is available

Reuse of injection
equipment
in South Asia
 Assume needles and syringes
are sterile if:
• Disposable, single use needles and syringes:
– Are purchased from a reliable manufacturer and are in
individual, undamaged and unopened packaging
• Sterilizable injection equipment:
– Is cleaned before sterilization
– Is processed in a sterilizer monitored with indicators
– Is sterilized under routine supervision
– Is designed to be re-usable
 Discard packages if punctured, torn or
damaged by moisture
• Damaged packages are not
sterile since germs or toxins
can contaminate injection
equipment if the outer
package is damaged

Check each package

for tears or damage
 Use a sterile syringe and a sterile needle
to mix each vial of medication and diluent
• It is not safe to change the
needle but reuse the syringe
• Do not use the same mixing
syringe to reconstitute
several vials
Use a sterile syringe and sterile needle for
every injection
• Open the package in front
of patients to reassure them
that the syringe and needle
have not been used before
If disposable syringes and needles are not
available, sterilize equipment
• Only sterilize equipment designed for reuse
• Disposable equipment, especially narrow needles,
cannot be sterilized safely with steam
 What is “sterilization” ?

• “Sterilization” refers to the

steps that reduce the
number of organisms on an
item to a safe level
• Boiling in an open pan,
soaking syringes and
needles in alcohol or
disinfectants does not
“sterilize” and is not safe
 Steam sterilization requires:

• Water, brushes and gloves to clean syringes and

needles of all visible dirt before sterilization
• Use of indicators
• Storage of sterile syringes and needles in a dry,
sealed container
• A system of routine supervision
 Sterilization must be monitored by
indicators and supervisors
• Indicators for steam
sterilization show if
conditions of time, steam
pressure and temperature
(TST) have been met
• TST spots are recommended
for immunization
programmes

TST spot
indicators
Auto-Disable (AD) syringes prevent reuse

• AD syringes disable
themselves after one use
• They have a fixed dose and
are currently used in
immunization and family
planning programmes
• They prevent reuse, but not
needle-sticks

AD syringe
 Outline: How to give injections safely

• Eliminate unnecessary injections

• Use sterile injection equipment and sharps
• Prepare and give injections without causing
contamination or needle-sticks
• Dispose of sharps to prevent reuse and harmful
waste
 Prepare injections in a clean,
designated area
• Do not allow blood,
specimens or contaminated
supplies supplies in this
space
• Keep the area free of clutter
so all surfaces can be easily
cleaned and disinfected
 Wash hands under running water

• Wash hands with soap or

disinfect with waterless
alcohol solutions before
preparing or giving
injections
• Wash hands again after
contact with soil, blood, or
body fluids
Follow manufacturers’ instructions for the
storage and use of each medication
• Some medications must be:
– Discarded after opening
since they have no
preservatives
OR
–Kept between 2-8 º C
OR
– Reconstituted only with a
specific diluent
 Use single-dose vials rather than multi-
dose vials, if possible
• Multi-dose vials have been
linked to many outbreaks
• If syringes are reused with
multi-dose vials the entire
vial will be contaminated
and can cause illness or
death
Use a sterile syringe and needle to withdraw
a dose and inject with the same needle
• Never leave a needle in the
vial. A needle left in the
septum opens the vial to
contamination
 Discard medication vials with
cracks, leaks or visible contamination
• While deadly contamination
may be invisible, visible
contamination or cracks in
the vial indicate that the vial
should not be used
• When in doubt:
– Throw it out
 Discard needles that touch hands,
surfaces or non-sterile objects
• Surfaces and hands contain
microbes (germs)
• Sterile devices become non-
sterile if touched
 Swabbing the tops of vials or ampoules
with a disinfectant is unnecessary

• Never store cotton wet in

disinfectant. All disinfectants
can become contaminated
and spread disease
• If vials are swabbed, use
individually packaged
isopropyl alcohol, or ethanol
- Never methanol
 Swabbing the skin prior to injection
is unnecessary
• Clean visibly dirty skin with
clean water and dry with
clean cotton
• If skin is swabbed, use an
individually packaged swab
of isopropyl alcohol or
ethanol
• DANGER!
– Most cleaning agents and
other alcohols (methanol or
methyl-alcohol) are not
safe for human use
 Do not open glass ampoules
with bare fingers
• Staff often cut their fingers
when opening glass
ampoules
• Bleeding fingers
contaminate vials, syringes
and the work setting
 Protect fingers from cuts when opening
ampoules
• Use clean pliers, two small
hinges, clamps made from
clean bent bottle caps, rigid
pieces of plastic or a carved
piece of wood
• While rigid materials protect
fingers better, a piece of
gauze may offer some
protection
During injections, prevent sudden patient
movements that may cause needle-sticks
• Many needle-sticks occur when children or adults
move unexpectedly. Restrain children gently and
securely in the lap of an adult with arms and legs
held
• Assess the mental condition of bed-ridden patients
and ask a co-worker to help restrain adult patients
who may be confused
 Do not recap needles

• Recapping commonly leads

to needle-sticks
• If recapping is necessary,
use a one-handed technique
 Gloves are not usually needed when
giving injections
• Disposable gloves may be Gloves
used to give injections if
excessive bleeding is
expected
 How to give injections safely: Outline

• Eliminate unnecessary injections

• Use sterile injection equipment and sharps
• Prepare and give injections without contamination or
needle-sticks
• Dispose of sharps to prevent reuse and harmful
waste
 After use, immediately put syringes and
needles in a puncture-proof sharps
container
• Keep a safety box where the
injections are given

• Do not store used sharps in

an open container where
they can be reused or cause
needle-sticks when dumped
Close safety boxes when they are 3/4 full
and lock boxes in a secure area
• Seal boxes to prevent
persons from removing
needles to reuse them.
Locked storage may be
needed if persons sell used
syringes.

• Needle-sticks can occur if

boxes are overfilled
 Know how syringes are stored and
destroyed at your facility
– Tour your facility to see if used injection equipment is
visible in public areas
– Know how and where used syringes are stored
– Find out how syringes are destroyed at your facility
– Used sharps in the environment is a sign that the medical
waste handling needs to be improved

Health care Use of an

waste in the incinerator in
environment in Africa Central Asia
 Unfortunately, managing waste in an efficient,
safe and environment-friendly way is not easy

• Without efforts to keep

syringes separated from
routine waste, syringes can
appear on the clinic grounds
and lead to reuse and
needle-sticks
• Facilities with incinerators
need supervision, skilled
staff and procedures to
encourage safe
management
Technical information on medical waste
disposal is available from WHO

www.healthcarewaste.org
 These recommended techniques should
be applied only to ID, SC and IM
injections
• Different recommendations, including those for skin
preparation and use of gloves, exist for:
– Intravenous administration of medication and fluids
– Blood cultures
– Needle-free injections
For more information...

The SIGN Secretariat

World Health Organization

Department of Blood Safety

and Clinical Technology

Avenue Appia, 20
1211 Geneva,
Switzerland

Email: [email protected]
www.injectionsafety.org