Needlestick Injury during Disposal of Blood-Collection Needle
Hazard [Health Devices Aug-Sep 1994;23(8-9):270-1]
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.
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
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.
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.
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.)
- 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