Cause of Device-Related Incident
Device factors; Support system failures; User errors

Clinical Specialty or Hospital Department
Clinical Laboratory; Infection Control; Pharmacy / IV therapy

Device Factors
Design / labeling error

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Exposure to bloodborne pathogens; Misdiagnosis

Support System Failures
Error in hospital policy; Failure to train and / or credential

Tampering and/or Sabotage
*Not stated

User Errors
Failure to read label; Incorrect clinical use

UMDNS
Needles, Blood-Collecting [12-736]; Blood Collection Tube Adapters [17-814]; Blood Culture Kits [10-425]; Waste-Disposal Units, Sharps [14-423]

Needlestick Injury during Disposal of Blood-Collection Needle



Hazard [Health Devices Aug-Sep 1994;23(8-9):270-1]

Problem

A member hospital reported that a needlestick injury occurred when a technologist was removing a direct draw adapter from a butterfly blood-collection needle to discard the needle in a sharps container. The patient's blood was HIV positive. Although this injury occurred with a specific manufacturer's product, we believe that a similar injury could occur with the use of other manufacturer's blood-collection tube adapters designed for specific blood-culture bottles.

Discussion

Butterfly blood-collection needles consist of a needle on the butterfly end that is inserted into the patient and a rubber-covered inner needle on the other end that is inserted into a blood-collection tube or blood-culture bottle. The rubber-covered inner needle can be attached to a blood-collection tube adapter, consisting of a barrel designed to accommodate certain blood-collection tubes or the wider necks of blood-culture bottles, to keep it in place.

In the reported incident, the technologist had been drawing blood into blood-collection tubes using a butterfly needle with the direct draw adapter. The short, wide barrel of this adapter is designed to accommodate the necks of blood-culture bottles; however, because the user can easily contact the inner needle, this design also increases the risk of needlestick injury.

Although the direct draw adapter is designed for a single use and is intended to be discarded along with the needle, the hospital states that its policy is to have all personnel routinely disconnect needles from blood-collection tube adapters (i.e., to allow reuse of the adapter and use of a smaller sharps container for needle disposal). The technologist followed the hospital's needle-dismantling procedure of holding the adapter and unscrewing the needle into the sharps container. During this process, the technologist sustained a needlestick injury from the contaminated inner needle beneath the rubber covering. The sharps container used in this incident was small enough (1.4 L) to fit on a phlebotomy tray and was intended primarily for discarding needles; according to the hospital, it was not full at the time of the incident.

Alternative procedures are currently being used in hospitals for collecting blood-culture samples. One alternative is using a syringe and needle to draw the sample and then placing the needle into the culture bottle. This procedure is more dangerous than using a direct draw adapter and may also cause contamination of the sample.

Manufacturer Action

The supplier of the direct draw adapter states that it is unaware of any other needlestick injuries with this device and that it has no plans to change the design. This adapter has always been intended for a single use, as noted on the adapter and product insert. The supplier has modified the precaution in its product insert to more strongly emphasize that the product is intended for a single use only and is not to be disassembled before disposal.

Recommendation

When using any blood-collection needles with a direct draw adapter or another similar blood-collection tube adapter designed for specific blood-culture bottles, dispose of the entire assembly in an appropriately sized sharps container. Do not attempt to separate the adapter and needle before disposal. (Note: It may be necessary to use a sharps container located in the patient's room instead of one located on a phlebotomy tray.)

UMDNS Terms

  • Needles, Blood-Collecting [12-736]
  • Blood Collection Tube Adapters [17-814]
  • Blood Culture Kits [10-425]
  • Waste-Disposal Units, Sharps [14-423]

Cause of Device-Related Incident

Device factor: Design/labeling error

User errors: Failure to read label; Incorrect clinical use

Support system failures: Error in hospital policy; Failure to train and/or credential

Mechanism of Injury or Death

Exposure to bloodborne pathogens; Misdiagnosis

 


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