Safe injection practices

by
Dr. D.S.Chandel
Former Director Health Services
Himachal Pradesh (India)
email:ds.chandel26@gmail.com
Mobile:9418105470

by
Dr. D.S.Chandel
Former Director Health Services
Himachal Pradesh (India)
Mail:ds.chandel26@gmail.com
Mobile:9418105470

•World wide1670 crs.
•In India only300 crs.
•Unsafe in India189 crs.

53%
40-
75%
90%
75% Unsafe handling of BMW
Reuse of disposable syringes &
needles
Inadequate sterilization (now
disposable)
Wrong technique

21.7 millions
HBV
2 millions
HCV
96,000 HIV
•33% NEW
CASES
•42% new
cases
•2% NEW
CASES

Total
injections
16.7 billions
5% for
immunization
(74% unsafe)
5% blood
transfusion &
family planning
90% therapeutic use
(majority of them not
required)

• Immunization & Family planning17%
• Therapeutic use83%
• In OPD in public HI. More in private HI44%
• Fever, cough, diarrhea (not required)52%
• Unsafe63%

Blood born infections, among
health staff, due to unsafe
injections & occupational
injuries
Incidence of
HIV -4.4%
Incidence of HBV
& HCV-39%

2000-2010
2007
2014
• >35 outbreaks of
Hepatitis in USA
• Outbreak of HBC
Nevada (USA)
• 200 cases of HIV
Battambang
(Combodia)

28%
25%14%
11%
11%
11%
Injections
Venepunture
Suturing
Manipulating IV inj. Port
Inserting IV catheter
Other medical procedures

61%
45%
Institutional level
Terminal level

5 to 50% inj. Given with reused syringes
During 1995: in 94% cases by reusing
injection equipments
In rural India: 50% receive injections on
doctors choice
70% patients demand injections.

2.4 to 13.6 injections/person/year
In India: 2 to 8.6 % injections/
person/year
Another study: Frequency of injections
increased from 2.1% in 1987 to 2.9% in
2001.

❖A Centre for disease control & prevention
(CDC) report published in Journal of American
Medical Association (JAMA) June 9,2010:
Incidence of use of Single dose vial for > 1
patients 28.1 %.
❖ Another study reports: 1.3 million deaths/
year & a burden of 535 million US$/ year due to
unsafe injections.

 National Centre for Disease Control
(NCDC), New Delhi, had issued guidelines
for safe injections in the form of a “Hand
book on Safe Injection Practices”, in July
2014, under NHM.

Risk to patients to contract infection.
Risk to provider to contract infection.
Poor BMWM: Risk to community.
Increase in treatment cost.
Loss of productivity.

It is a medium to administer a
drug, into the body, for curative
or preventive purpose
Safe injection practices should not be sacrificed to save
money and time.

Harmless to
the patient
Harmless
to the
provider
Proper
BMWM
Immunization of the staff; constant
supply of material, trainings
As above; sensitization of community
Unsafe to the community and
environment; sensitization.

Correct technique
Proper BMWM
Immunization of staff
Injections are given, only when required

Some patients believe, injections
act fast.
Some doctors prefer injections,
as they think:…………….

• Wrong notion.It is best form of
treatment
• Needs patient’s
counseling.
Provides satisfaction
to the patients
• Unethical
practice.
Due to commercial
reasons/credibility

•Reuse of injection equipments; syringes and
cannulae.
•Changing the needle to reuse the syringe.
•Using same syringe for mixing solvent in different
vials.
Improper Biomedical waste management

Not cleaning the injection site.
Touching the needle.
No hand wash/ not using PPE’s.
Flushing the syringe & needle before injection.
Injection over the clothes.
Keeping needle in the MD vial/unhygienic storing of MD vial.

Wrong selection of site.
Inadequate exposure of the site/part.
Not checking the label of the drug.
Using SDV for >1 patient.
Recapping/One handed recapping of the syringe.

Sensitization of staff & community.
Behavioral change in clients & professionals.
Uninterrupted supply of sterile material & PPE’s.
Safe disposal of BMW.
Immunization of staff.

Immunization
Hospital
associated
infections
Hand washing
Use of PPE’s
Ensuring
constant
supply
Proper BMW
Correct
technique

Any
injections
HIV
HBV
HCV
Hepatitis
Malaria(only if, large
volume of Blood
transfusion)
Neglect of nursing
care

Cost of one pair of
gloves: Rs 10
Cost of 5 ml syringe:
Rs 5
Cost of a drip set:
Rs 45
Cost of 1 bottle
of normal
saline: Rs 25
Cost of one
IV cannula: Rs 35
TOTAL COST :
Rs 115
Drug extra

Intramuscular
injections
Infection Vascular injury
Hematoma
Nerve injury
Local
reaction
Allergic
reaction
Neurogenic
shock

INTRAVENOUS
INJECTIONS
Local
infiltration of
drug
Embolism
Hematoma
Thrombosis
Endarteritis
Neurogenic shock

Eliminating injections-best way
Immunization of staff-Hepatitis 1ml IM;
0,1,6 months
Availability & use of PPE’S
Proper BMWM
Steps byWHO/GOI to reduce injection.

Unnecessary injections.
Two handed recapping of syringe.
Improper handling of sharps.
Bins, located away from the point of generation.
Poor positioning of the patient.

Unsafe transportation of blood/ body fluids/tissue
samples
Poor technique
PPE’s not available/ not being used.
Poor hand hygiene

More injections-more waste.
Injections are given for fever, cough, diarrhoea.
1 injection= appx. 40-60 gms BMW; (Needles(2)-6gm;
syringe-5 gm; ampoule/SD vial/MD vial=3/10/20 gm;
gloves-20gm; cannula=20gm).
2005-Delhi produced 65 tons in 1 year BMW, due to
injections only.

Nil orally
Unable to retain
orally
Unable to
take orally
Unable to
absorb
No oral
preparation
of drug
Doubtful
compliance
Child/psychiatric
Semi/unconscious-
oral feeding not
possible
Acute severe
pain/high conc. Of
drug required

Preparation to give injection
Filling of syringe
Site selection
Preparation of skin
Giving injection
Proper disposal of BMW

Right
medication
Right route
Right dose
Right
documentation
Right
patient/site
Right time
Right disposal BMW

 Patient antecedents should be verified.
 Patient should be made comfortable and counseled.
Apprehensions discussed.
 Option of the selection of site for the injection, rests
with the patient.
 The injections should preferably be given in lying
down position.
 Hydrate the patient, (if not emergency) with 2 glasses
of water, 1 hour before.
 The part should be adequately exposed.
 Privacy of the patient should be ensured.
 Opening of syringes etc./filling in front of the patient.

▪ Syringe of appropriate volume/type selected.
▪ Parts of a syringe: barrel, plunger, needle. Hub.
 Types of syringes: (disposable)
➢ Auto disabled syringe:after single use: Active mechanized(had to
push to lock); Passive mechanized (self locking)
➢ Prefilled syringe.
➢ Syringe with fixed needle.
➢ Syringe & needle; packed side by side.
➢ Syringe & needle; packed end to end.
➢ Syringe; packed without needle.
➢ Safety syringe: needle gets locked with the hub.
➢ Glass syringe (not in use now).
➢ Syringes of different volumes.
➢ Prefilled saline flush syringe.

14 G
18 G
16 G
22 G
23 G
25 G
24 G
20 G
GREEN
PINK
ORANGE
GREY
BLUE
PURPLE
WHITE
YELLOW
21 G 26 GDARK GREEN LIGHT BROWN

 Plastic ampoule with breakable top.
 Plastic ampoule with non-breakable top.
 Glass ampoule with collar band (pop-open)/ one
point cut (OPC) ampoule.
 Glass ampoule without collar band.
 Single dose vial.
 Multi dose vial.
 Vial with drug in powder form.
 Vial with drug in liquid form.
 Solvent for the drug in “powder form”.
 Use of saline from IV bottle---NOT AT ALL.

 Water swab: used for I/M (therapeutic/ vaccination),
S/C, I/D. or otherwise advised by the manufacturer.
 Alcohol (70% isopropyl) swab: Used for IV, IM
(Therapeutic).
 Spirit swab, 70% isopropyl alcohol not for vaccination
and must for IV injections.
 Option: Disposable alcohol swab are being
preferred for all injections: then let it dry x 30 secs.
 Never use presoaked swabs.
 One patient-one swab-only one time.
 Methyl alcohol unsafe in human use.

 Syringe(0.1 ml to 20 ml) and needle of proper
volume and gauze.
 0.5 ml drug not in 5/10 ml capacity.
 I/M –23/24 G, SC/ID—25/26 G, IV-18/20 G.
 24-26 G: children/infants.
 22-24G: Child/elderly.
 20-24 G: post op/medical.
 18G: rapid fluid/blood infusion.
 16 G: for trauma cases, where large volume
fluids are to be infused in short time.

 Double check the vial/ampoule for name,
dosage, expiry, color change, foreign
particles, damaged vial(broken/dented top),
leakage. Previously opened…date/SD/MD.
 If any of the above: discard.
 Ensure that the drug is at room temperature.
 If taken out from refrigerator: warm it by
rolling between two hands or keep in a hot
towel.

❖ In the injection room/indoor/emergency:
➢ Intra dermal
➢ Subcutaneous
➢ Intravenous
➢ Intramuscular
❖ Under OT conditions: as above &
➢ Subdural, epidural, intra-articular, in the bursa,
injection/putting needle into the body cavities.
❖ Community level:
➢ Tattooing procedures.

 Multi dose vial—don’t leave the needle in the
cap.
 Fresh sterile needle and syringe used for filling
every time.
 Remove the outer seal (central metal cap)
completely.
 Top of the rubber stopper/diaphragm cleaned
with friction with spirit/ 70% isopropyl alcohol.
Leave for 30 seconds to let it dry.
 Stored separately, after use, under prescribed
environmental conditions in refrigerator. Do not
freeze it. Do not store in open ward.

 Time and date of opening/ reconstitution
written with signature.
 Do not use after 24 hours (national guidelines) or
as recommended by the manufacturer.
 Preservative: no effect on viruses: HVC,HVB,
HIV.
 Check every time for color change or growth.
 Single vial preferably for the same patient. Put
the name of the patient with bed number in
addition to the time/date of opening.
 Do not store in the door panel of the
refrigerator.

 Preferred: less chances of contamination.
 Used for one patient/procedure/injection only.
 Pop-open/one point cut (OPC) ampoules should
be preferred (ring around or dot on the neck).
 Use of ampoule cutter & gauze piece, while
breaking.
 Loose pieces into the ampoule/on the floor.
 Typically lacks preservative, so discarded after it
is accessed once.
 6% health professionals in USA using SDV >1
patient.

 Proper solvent as prescribed (not NS bottles).
 Hub cutter.
 Use Auto disabled syringe ???.
 Color coded bins.

 Find out: whether the injection is prefilled/ ready to
use/liquid form/powder form or whether it requires
filling from ampoule or vial.
 Syringe should be opened immediately before use.
 The pack of syringe should not have any puncture.
 Medication should be prepared as close to the patient
as possible.
 Do not transfer the medication from one syringe to
the other.
 Do not place the vial on contaminated surface or used
procedure tray.
 Do not transport the vial, syringe or needle in pocket.

 Hand Washing x 30 seconds with soap &
water. Decontaminate with alcohol, if hands
are visibly “not soiled”.
 Wear gloves.
 Trimmed nails, it may tear the gloves.
 No source of infection (may apply water
proof dressing).
 Skin integrity of provider.
 No rings in the fingers/ wrist watch.
 Sleeves should be folded up.

 Double check the label for correct name, foreign
particles, expiry, color change, damage to the
vial (any dent/break).
 Ensure the drug is at room temperature.
 Dissolve the drug by rolling the vial between two
hands, if solvent is being used.
 Hold the ampoule vertically, tap it gently,
ensuring no fluid is there in the upper portion.
 While breaking, ensure that glass particles do
not fall into the ampoule or on the ground.
 Use of glass cutting knife or ampoule cutter.

 Syringe with end to end packing: Ensure that the
needle is fitted on the syringe.
 Syringe with side by side packing: open the syringe
keeping in mind that the needle doesn’t fall down.
 Open the needle (18G) from the upper end by de-
sticking/peeling off the wrappers.
 Open the syringe packet from upper end, in front
of the patient.
 One needle, for one filling, at one time.

 Glass ampoule: hold the ampoule in left hand
and cutter in right hand. Use gauze piece. Use
the collar band.
 Plastic ampoule with breakable top: break the
top of the ampoule by bending it.
 Plastic ampoule with non-breakable top: had to
puncture with the needle.
 Vial: remove central metal piece/seal completely
from the cap.

 Remove the cap from the needle- green bin.
 Hold syringe in the writing hand and vial in the
other hand, fill equivalent air, raise the vial with
upside down at an angle of >45°,push the needle
into the vial cap.
 Less air– vacuum, more air—leakage of liquid.
 Ensure that the tip remains dipped into the liquid.
 Do not fill air into the AD syringe.

 Take out the needle, keep the vial on table.
 Hold syringe with needle upward, tap with
fingers to settle the air bubbles & then
remove the air.
 Do not recap the syringe, until is very
essential– may cause injury, increase in BMW.
 In case needed—recap with single hand: one
handed scoop technique.
 Do not wipe the needle.
 Do not touch the needle.

 Basic principle—minimum possibility of injury
to nerves and vessels.
 Skin free from any bruise, hair, scar, rash or
other lesions.
 Open display of the part. Ensure the anatomy is
not disturbed.
 Preferably alternate side/limb.
 Repeat injection on the same limb/area: 1” apart.
 Patient made comfortable.
 While piercing the skin, the bevel of the syringe
should face upwards. Minimum surface area of
the needle touches the skin surface.

 Deltoid: 1-2" below the acromion process. For
>3years age. Not for thin built, patients with poor
musculature.
 Ventrogluteal : upper and outer quadrant. Adult,
children >7 months.
 Dorsogluteal: Not for <3 years.
 Thigh—middle 1/3; antero-lateral surface of middle
thigh-Vastus lateralis. Good for <3 years.
 <7months:ventrogluteal, <3 years: Vastus lateralis;
>3years: Deltoid/dorsogluteal.

 Flexor aspect of forearm, outer aspect of
upper arm…..
 For test dose: the quantity of the solution is
0.01 to 0.1 ml. (0.1 ml is universal).

 Anterior abdominal wall (s/c)—5 cm area
around umbilicus ( except central 1cm.)
 Flexor aspect fore arm.

 Cubital/ wrist/ forearm.
 Scalp in children.
 Dorsum of hand & foot.
 Dorsum of hands and foot are painful
because the nerves are very close to the
vessels.
 Brachial in dialysis.

 Clean the skin inside out circularly.
 Spirit swab:30 seconds (IV, IM (therapeutic)).
 Soap water/plane water swab for ID,SC,IM
(vaccination). Disposable alcohol swabs can
also be used for all injections, but let it dry
x minimum 30 secs.
 Swab single use.
 Methyl alcohol unsafe in human use.

 Table should be made free of items/ away
from the patient.
 Stabilize the child by holding the child’s legs
and hands tight.
 Needles of lesser gauge and length.(23 to 26
gauge).

 Angle 10 –15 degree, bevel upwards with the writing
hand. Stabilize the skin by stretching with the other
hand.
 Push the needle 2-3 mm within the layers of
skin(hypodermis).
 Push the drug.—wheel formation.
 Encircle/mark the margins of wheel/bleb, if it is test
dose.
 Cover it with the swab, till weeping stops.
 Do not press/rub.
 Do not touch with spirit.
 BCG, tuberculine test, anti rabies, test dose.
 Possible to tear the skin.

 Inj. Insulin, inj. erythropoietin etc.
 Hold like a pencil in the writing hand.
 Hold a fold of skin with other hand to
separate it from muscles.
 Push at 45° to the skin.
 Leave the skin fold slowly.
 Push the drug slowly X 5 –10 seconds.
 Used for slow absorption of drugs—less blood
supply.

 Clean the skin with the prescribed swab with the
writing hand, let it dry. Do not touch it now.
 Hold like a pencil between the thumb and index
finger of the writing hand, barrel resting on the
index finger.
 Stretch the skin downwards. Prick the skin at
90°.
 Pull back the plunger to ensure the needle is not
in the vessel (not in case auto-disabled syringe is
being used).

 If blood leaks into the syringe, discard it & use
a fresh syringe & drug.
 Do not inject the drug by pushing hard. Some
drugs cause pain: drug makes space.
 “Z” entry (valvular) of the needle by pushing
the skin to avoid leakage of blood/drug if any.
 Pull the needle in the same direction.
 Rich blood supply –quick absorption.

 Use different site/limb/side every time.
 It helps to prevent scar formation and skin
changes.
 The sites, where injections are given, should be 1"
apart from each other.

Lump, bleeding/bruise, numbness, pain,
fever.
Emergency consultation: hives, rash
dyspnoea, sneezing, itching, swelling of
face/lips.

 Drug injected directly into the vein so extra
precaution required.
 Make the vein prominent:
❖ Hydrate the patient. Two glasses of water, 1 hour
before.
❖ Coming from cold atmosphere outside, let the
body getting warm.Take some hot beverage.
❖ Warm the area by wrapping a warm
towel.(microwave towel x15-30 secs.
❖ Soak the injection site with warm water.

❖ Warm the injection site with hair dryer.
❖ Rotate the arm. Centrifugal force makes the vein
prominent.
❖ Let the arm fall from the side of the bed/sofa X 2
minutes.
❖ Open and close the hands/ flex/extend the elbow
X 30 secs.
❖ Press the area up and down in gentle bouncing
motion, it expands the vein. Do not slap the area
as it stimulates nerves along side the vein which
causes vasoconstriction.

 Apply tourniquet 2-4” above the injection
site to make the vein prominent.
 Alternatively BP cuff can be used, which is
inflated above the diastolic pressure.
 Difficult to locate vein, if patient is
debilitated, dehydrated.

 Hold the syringe at 25° to the skin.
 Keep the bevel upwards.
 Ensure valvular pathway by pricking skin &
vein at different points or downward
stretching of skin.
 Prick the vein and ensure that the tip of
needle stays inside the vein.
 Remove the tourniquet
 Push the drug slowly and then pull the needle
out in the same direction.

 Gently press the area/fold the arm at elbow if it is
cubital area.
 Blood leakage—press gently X 1-2 minutes.
 Secure the swab/gauze with a adhesive tape.
 If cannula use: regular flushing of cannula with
prefilled saline syringe (5ml 0.9% NS), 2ml before & 3
ml after administering drug.
 I/V Cannulae; change after every 48-72 hrs. DEHP.
 While fixing the cannula, the adhesive tape should not
circle the limb for more than 2/3 of its circumference.
 Remove gloves-red bin. Sanitize/wash hands.

 Remove the cap.
 Clean the area around the opening/injecting
site with alcohol swab.
 The swab should not be very damp, not to
allow alcohol to spill inside the opening.
 Let it dry, fit the nozzle of the syringe and
then slowly administer the drug.
 Disconnect the syringe. Replace the cap.

 Patient should not be allowed to leave for ½
hour.
 Patient should be observed for any untoward
reactions.
 In case of any such incidence, doctor should
immediately be called.
 The incidence should be documented and
patient should be informed in writing, the
drug to be avoided in future.

 The waste should be segregated as per rules.
 The needle should not be burnt. If it is done then one
should put on mask. Dispose it in white translucent
puncture proof container.
 The hub of the syringe is cut and piston is drawn a bit
and broken. Dispose it in red container.
 Plastic ampoule into red container.
 Broken glass ampoule /vial into the blue container.
 Gloves into the red.
 Swab into yellow container.
 Packing material, needle caps into green container.

1.Aseptic technique is used to avoid contamination of sterile
injection equipment.
2.Used syringes and cannulae are shredded immediately and
segregated as per BMWM Act at the point of use.
3. Needles are not shredded.
4. Single-dose vials are used, whenever possible and discarded
immediately after use on a single patient.
5.Medications are not administered from one syringe to multiple
patients, even if the needle or cannula on the syringe is
changed.
6.Needles, cannulae, and syringes are sterile, single-use items
and should not be reused for another patient or to access a
medication or solution that might be used for a subsequent
patient.

7. A syringe or needle/cannula is considered contaminated,
once it has been used to enter or connect to a patient's
intravenous infusion bag or administration set.
8. Medication is not prepared in one syringe to transfer to
another syringe??????.
9.A sterile syringe and needle/cannula is used, when
entering a vial--never use the one, which has been used
on vial or other patient.
10. MD Vials are discarded 24 hours after opening, unless
specified by the manufacturer, or sooner if sterility is
questioned or compromised.

11. Multi-dose vials are not kept in the immediate
patient treatment area and are stored in accordance
with the manufacturer's recommendations.
12. A needle or cannula is never left inserted into a
medication vial rubber stopper, because it leaves the
vial vulnerable to contamination.
13. Fluid infusion and administration sets (i.e.,
intravenous bags, tubing, and connectors) are used
for one patient only and discarded appropriately
after use.

14. Bags or bottles of intravenous solution are not used
as a common source of supply for multiple patients.
15. Once IV solution bags have been spiked;
administration must begin within 1 hour.
16. All opened vials, IV solutions and constituted drugs
or opened syringes, that were used/partially used in
an emergency situation are discarded.
17. Bags, used to store sharps, should be sealed
properly before transportation.

75-93%- No hand washing/use of gloves
33%-Placing syringe in tray after filling
30%-Recapping syringe with both hands
25%-Touching the needle

23%-Reuse of syringe or needle >once
4-11%-Flushing the syringe before filling
7-11%-Wiping the needle
7%-Over the clothes

32%-multi-dose vial not cleaned before use
59%-injection site not properly cleaned

 One way traffic.
 Facility to lie down.
 Privacy.
 Sitting arrangement. Bed to lie down, in case
of any reaction.
 Facility of proper BMWM.
 PPE’s.
 Hand washing facility (tap, water, soap, towel
etc.) & HW habit. Sanitizer.
 Wash basin.

▪ Examination table.
 Bed.
 Almirah.
 Refrigerator.
 Stool, bench.
 Chair & table for staff.
 Color coded bins & hub cutter.
 Drip stand, oxygen cylinder, ambu bag.
 Above all proper training to use the facility.

 Emergency tray: syringe, Injs. adrenaline/
hydrocortisone/ avil/ atropine.
 Fluids: dextrose, normal saline.
 IV cannula, cotton, gauze, mouth gag,
tongue depressor.

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