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Alarming Survey Results from CDC: Unsafe Injection Practices Continue

To safely prepare and administer an injectable medication, practitioners must follow aseptic technique, avoid reuse of single-dose or single-use vials, use needles and syringes just once for only 1 patient, and never reenter a medication container with a used needle or syringe. However, the results of a recently published survey1 conducted by the Centers for Disease Control and Prevention (CDC) on injection practices in acute care, long-term care, and outpatient settings, revealed dangerous knowledge gaps, attitudes, and practices by physicians and nurses; this despite widespread media coverage of more than 50 outbreaks associated with unsafe injection practices since 2001 and the launch of the national One & Only Campaign in 2009 by the Safe Injection Practices Coalition. The One & Only Campaign aims to raise awareness among patients and practitioners about safe injection practices. The national campaign provided funding to state health departments in Nevada, New York, New Jersey, and North Carolina to help promote the campaign due to high-profile outbreaks in these states linked to unsafe injection practices. While most surveyed physicians and nurses were aware of the outbreaks, awareness of the campaign was low (22.7% for physicians, 20.0% for nurses), although somewhat higher in physicians and nurses in states that received funding to promote the campaign (59.5% for physicians, 54.7% for nurses). Moreover, the survey revealed alarming misperceptions regarding the acceptability of injection practices that are clearly unsafe, along with unsafe practices in the workplace. Details from the published survey results1 follow.

Survey respondent profile and questions

The survey was completed by 370 physicians with a median of 14.5 years of clinical experience, and 320 nurses with a median of 21 years of clinical experience. The physicians’ specialties included anesthesiology-pain management, dermatology, gastroenterology, internal medicine, orthopedics, oncology, and radiology. All nurse participants were registered nurses who were working at least half of the time in a clinical setting. Participants were either from the 4 states that had received funding to promote the One & Only Campaign message or from 4 other states that had not received funding (Colorado, Tennessee, Montana, Wisconsin). Along with knowledge and attitudes associated with injection practices, nurses were asked about the frequency of their own injection practices in the workplace, and physicians were asked about the frequency of injection practices by all healthcare personnel in their work area, not just their own practices.   

Highlights of survey results 

While most physician and nurse responses to the survey aligned with CDC recommended injection practices, there is a dangerous minority of practitioners—perhaps many more than previously thought—who are violating basic infection control practices associated with the use of syringes, needles, single-dose vials, diluent containers, and other unsafe injection practices.

Syringe reuse: Survey responses indicated that 12.4% of physicians and 3.4% of nurses reuse a syringe for more than 1 patient, despite findings that most physicians (91.6%) and nurses (99.4%) do not agree that this is an acceptable practice. Almost 5.0% of physicians reported that this unsafe practice usually or always occurs in their work area. This unsafe practice was most frequently reported by oncologists; 17.9% of oncologists thought it was an acceptable practice, and 23.9% reported its occurrence in the workplace (13.5% reported this usually or always occurs). While statistical analysis comparing nurse practice locations did not occur in this study, little or no differences were seen in either attitudes or practices associated with syringe reuse in acute care, long-term care, or outpatient facilities.   

Reentering a vial with a used syringe/needle: While 12.7% of physicians and 6.7% of nurses mistakenly believed that reusing a syringe to access a medication vial is an acceptable practice, even more reported its actual occurrence in the workplace: 43.2% of physicians and 24.1% of nurses reported reentering multiple-dose vials with a used syringe (7.3% and 5.0%, respectively, reported this usually or always occurs). Belief that this was a safe practice was highest with oncologists (25.5%) and radiologists (20.0%), and its practice was reported in the workplace by more than half of all anesthesia-pain management physicians (63.4%), radiologists (57.5%), and oncologists (53.7%). Nurses in long-term care facilities (27.3%) and outpatient facilities (21.8%) reported reentering a vial with a used syringe/needle more often than nurses in acute care facilities (16.1%).

Using single-dose vials for multiple patients: The misperception that using a single-dose vial for more than 1 patient is an acceptable practice was high with physicians (34.0%) and nurses (16.9%), although the frequency of occurrence in the workplace was reported by fewer, although still substantial, physicians (25.1%) and nurses (10.9%). This unsafe practice was reported most often by oncologists (34.4% overall, 10.5% reported this usually or always occurs) and anesthesia-pain management physicians (31.7% overall, 9.8% reported this usually or always occurs). Little or no differences were seen in using single-dose vials for multiple patients by nurses in acute care, long-term care, or outpatient facilities, although more nurses in outpatient facilities believed the practice was acceptable. 

Using source bags or bottles as diluents for multiple patients: Using bags or bottles of IV solutions as a source supply of diluent for more than 1 patient was reported by 28.9% of physicians and 13.1% of nurses. This unsafe practice was reported by nurses more often in long-term care and outpatient facilities than acute care hospitals, and by oncologists (44.8% overall, 14.9% reported this usually or always occurs). However, orthopedists and dermatologists also reported that this practice occurs frequently (7.5% and 7.3%, respectively, reported this usually or always occurs).

Impact of campaign: When comparing the acceptability and frequency of unsafe practices of physicians and nurses located in the One & Only Campaign and non-campaign states, there were no statistically significant differences in responses (except regarding the acceptability of using a single-dose vial for more than 1 patient with physicians).

Comparison to prior survey

In December 2010, ISMP summarized the results of an online survey of more than 5,000 healthcare practitioners that revealed a lapse in basic infection control practices associated with injection practices.2,3 Seven years later, the results of the CDC survey suggest that the lapses continue and may have significantly worsened. For example, in the 2010 survey, 1.0% of all respondents reported reusing a syringe for more than 1 patient, versus 12.4% of physicians and 3.4% of nurses in the 2017 survey. In the 2010 survey, 15% of respondents reported using the same syringe to reenter a vial numerous times, versus 43.2% of physicians and 24.1% of nurses in the 2017 survey. Keep in mind that, in the 2010 survey, healthcare practitioners were asked about their own practices, as were nurses in the 2017 survey. However, physicians in the 2017 survey were asked to report the frequency of unsafe practices by all healthcare personnel in their work area, not just their own practices. In the 2017 survey, physician reporting of unsafe practices by healthcare personnel in their work area is higher than nurse self-reporting of unsafe practices. While physician attitudes regarding the acceptability of unsafe practices in the survey are clearly their own and reflect the degree of knowledge deficit that needs to be addressed, the physician responses in the 2017 survey regarding the frequency of unsafe injection practices in the workplace are more reflective of practices by all healthcare personnel and may more accurately reflect the scope of the problem.


The results of this latest study demonstrate that a dangerous minority of healthcare practitioners are violating best practices associated with safe injections and are placing patients at risk of serious infection. Given these lapses in infection control practices, academic institutions and programs, licensing bodies, and healthcare providers must enhance their ongoing surveillance of proper technique and devote resources to ensure students and staff have the knowledge and skills associated with even the most basic concepts of infection control and injection safety. Given that a higher proportion of oncologists, anesthesia-pain management physicians, and radiologists reported unsafe injection practices occurring in their work areas and reported the most concerning attitudes related to injection practices, these practitioners should be included in surveillance and educational activities. All staff should understand that any form of syringe and/or needle reuse is dangerous and should be avoided, and that syringes cannot be reused even if the needle is changed. Healthcare practitioners should be vigilant in following the current CDC guidelines that recommend that syringes and needles be used only once. Single-dose or single-use vials should only be used for 1 dose for 1 patient, and then discarded after initial entry into the vial. If multiple-dose vials are used, they should be limited to single-patient use whenever possible, and both the needle and syringe used to access the vial must be sterile. 

State licensing boards and professional specialty organizations could play a larger role in including injection safety training as a continuing education requirement. But until this happens, education on safe injection practices should be required during orientation and at ongoing intervals thereafter, and staff competencies in this important area of practice should be assessed regularly. Provider campaigns, such as the One & Only Campaign, are available to support safe practices in any setting where injections are delivered but should not be relied upon alone to promote safe injection practices. A multifaceted approach to surveillance and education is needed.


  1. Kossover-Smith RA, Coutts K, Hatfield KM, et al. One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety. Am J Infect Control. 2017;45(9):1018-23.
  2. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38(10):789-98.
  3. ISMP. Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed. ISMP Medication Safety Alert! 2010;15(24):1-3

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