1. Introduction

Safety in the workplace is an essential characteristic of occupational health measures [1]. Health care organizations should establish a safety culture that requires all care processes and human resources to concentrate on improving the safety of care provision [2].

The aim of medical interventions is to save lives and to promote health; therefore Health Care Workers (HCWs) have a responsibility to prevent transmission of health-care related infection. Observance of safe injection practices and associated infection control is important for protecting patients and HCWs [3].

Inappropriate injection practices have adverse effects and can potentially cause harm to many patients from blood borne pathogens and secondary infections, hepatitis B, C and epidural abscesses [4]. Studies in health workforce in developing countries demonstrate insufficient knowledge of hepatitis B virus infection and poor compliance with measures to prevent diseases [5–8].

The operating room (OR), as the site for anesthetic procedures, is one of the most medication-intensive areas in hospitals. Anesthesia providers use more drugs, particularly high-alert drugs, than any other units but they operate with fewer safety standards [9]. OR employees including anesthesia providers face a higher risk of infection from blood-borne pathogens than HCWs in other areas [6, 10]. This group of HCWs does not always follow standard precautions and do not report every injury [10].

Unsafe injection practice by team members administering anesthesia can include transmission of diseases, improper use of single-dose or multi-dose vials, and inappropriate use or reuse of infusion sets, syringes, and needles [11]. Processes of prescribing, mixing, relabeling and administering medication are reported to be done in anesthesia practice without proper observation of safety requirements [12]. Also, these processes can cause error in a crowded and stressful ORs environment [9].

Medication error is a frequent cause of adverse events in anesthesia and various factors contribute to increased likelihood of medication error in the anesthesia process. Among these factors are; use of potent medication, the complex and special environment of an OR and multiple responsibilities of the anesthesiologist in patient management [13].

Studies conducted in Iran have revealed low levels of knowledge and adherence to safe injection practice, and high occurrence of Needle Stick Injuries (NSIs) [14–16]. Other studies have also indicated unsafe injection practices [17, 18] and higher rates of NSIs in OR [19]. Furthermore, some scholars have reported less than optimal adherence to standard precautions in Iran [20, 21]. In addition, safety culture has been reported to be absent or weak in Iranian hospitals [22, 23] and medical education [23].

In summary, there has been little research on the status of medication injection safety in anesthesia in Iran. Administration of injections is an inevitable part of the anesthesia process including induction, maintenance and termination so the purpose of this study was to identify the status of injection safety practices by anesthesia providers in a teaching center.

2. Method

This cross-sectional prospective study was done during 2014–2015 in a 500-bed capacity teaching hospital affiliated with Urmia University of Medical Sciences (UUMS). The elected hospital is the largest referring and teaching hospital among the seven teaching centers in West Azerbaijan province with 3,365,000 populations in the northwest of Iran. Hospitals affiliated to Medical Sciences Universities are the largest group of hospitals in health sector of Iran.

The study employed a mixed-method approach of observations of injections in ORs and a survey of injection providers about adherence to safe injection practices at the hospital. ORs were located in two floors of hospital named as ORs group A and ORs group B. The type of surgeries was different in the two ORs groups. General surgery and Eye surgeries were performed in the ORs of group A. Neurosurgery, orthopedics, ENT and urology were performed in the ORs of group B. Injections were provided by anesthesia team members, including student nurse anesthetists, nurse anesthetists, anesthesiology residents and attending anesthesiologists (N = 85). The study participants were assigned to either group A or group B ORs, and did not rotate between group A or B for the period of the study.

Inclusion criteria were; having direct contact with patients; more than two years work experience, working in the morning work shift, and being an anesthesia trainee (resident or nurse) with at least 3 semesters of training in the hospital. Exclusion criteria were: working on evening or night shift and unwillingness to participate in the study.

3. Results

During the study period, 345 individual injections were observed (53% in group A ORs, 47% in group B ORs) to evaluate adherence to injection safety practices. Nurse Anesthetists performed 45.5% (157/345) of observed injections. Eighty-two questionnaires were completed and returned (96.5% response rate) by providers regarding local adherence to and knowledge of injection safety. Demographic data of providers is shown in Table 1.

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Table 1. Demographic and background characteristics of anesthesia injection providers (N = 82).

https://doi.org/10.1371/journal.pone.0207572.t001

3.1. Observation data

According to observation data, the highest compliance with safe injection requirements was observed in the items; “standard disposable syringe was used for the injection” (99% of injections) and “for this injection, a syringe and needle was taken from a sterile unopened packet” (98% of injections).

The lowest compliance with safe injection requirements was observed for the items; “reconstitution of a medicine performed using diluents from the same manufacturer” at 17% and hand hygiene, with only injection providers washing their hands only 19% of observed injections, and using alcohol-based hand rub only 15% of the time (Table 2). Overall, safety requirements were observed in 61.28% of injections with considerable variation in values of items (minimum = 15.4, maximum = 99.4, Standard Deviation = 33.58).

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Table 2. Frequency and percentages of observed injection practices in ORs.

https://doi.org/10.1371/journal.pone.0207572.t002

3.2. Reported adherence to safe injection practices

On average, 80.3% and 79.7% of questionnaire respondents reported that sterilizable needles and syringes had never been used in their hospital for injections and for blood/fluid sampling, respectively. Needle removers or needle destroyers were used in only half (44%) of injections. Thirteen percent of respondents had never reported NSIs or sharps injuries to a person in charge and 17.1% of them sometimes reported NSIs or sharp injuries.

The teaching center had provided the necessary supplies for injections in 88% of cases. Twenty four percent of respondents reported that there had been stock-outs of puncture resistant sharps’ containers “sometimes” during the past six months.

Guidelines outlining post-exposure management procedures were available in the ORs “always or often” from the viewpoint of 53.7% of respondents (n = 44). Forty two percent of respondents (n = 35) confirmed availability of training regarding injection safety within the last two years. Supporting and counseling for blood and body fluid exposure, “always or often” was reported by 55% of respondents (n = 45) (Table 3).

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Table 3. Frequency of reported adherence to injection safety practices.

https://doi.org/10.1371/journal.pone.0207572.t003

Accidents from NSIs or sharps injuries were reported by 45% of providers (n = 37). Such incidences had occurred in 18.2% of providers (n = 15) once and 12.4% of them (n = 10) twice in the last six months. 85% of respondents (n = 72) had received at least one dose of hepatitis B vaccines.

Only 55% percent of respondents (n = 46) knew that hepatitis B, C, and HIV are blood borne diseases, and only 26% of respondents (n = 22) believed that only hepatitis B can be transmitted by injection (Fig 1).

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Fig 1.

Percentages of injection providers who correctly knew that HIV, hepatitis B and C can all be transmitted by unsafe injection practices.

https://doi.org/10.1371/journal.pone.0207572.g001

Forty eight percent of respondents (n = 39) had received three dose of hepatitis B vaccine (Fig 2).

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Fig 2. Percentages of injection providers who had received three doses of hepatitis B vaccine.

https://doi.org/10.1371/journal.pone.0207572.g002

4. Discussion

Patient safety is a relatively new field in Iran as patient-safety-friendly hospitals started in this country in 2010 [25]. Medical and paramedical staff are the most important performers of patient safety practices including injections [26]. This observational and questionnaire study showed that reported adherence of the staff to safe injection practices was acceptable but their actual practices were unsafe. Knowledge of providers was moderate about diseases transmitted by injections. The observed and reported adherence to safe injection practices was complementary in some respects.

The WHO developed the observational method and questionnaire [24], to help hospitals, health systems, and even nations determine where the practices are good and where they are not. This will help leaders develop educational and training programs, or audits to encourage compliance with safe injection practices and finally, safety culture.

Results of the Ford study in ORs showed that 22% of providers had used the same needle or syringe to withdraw medication from a multi-dose vial [11]. In this study, re-use of the needles were considerably higher. This remarkable difference may have been caused by a lack of attention to staff training and supervision, or regular audits. Another factor was frequency of withdrawal of medication for anesthesia maintenance.

In a study conducted by Abkar, recapping after injection was observed in 61% of injections and packed needles and syringes were used in 98.8% of observations [27]. Kaphle reported recapping in 94.1% of injections [28]. Omorogbe reported that 23.0% of respondents recapped used needles regularly and 32.8% of them recapped sometimes [29]. The rate of recapping were 58% in the studies of Vong and Paul [30, 31]. The relevant values were also high in this study and had Similarities and differences with the above-mentioned studies.

According to the WHO guidelines, the needle should be discarded after an injection without recapping [30, 32]. In anesthesia processes, there is probably a high recapping rate because of repeated use of previously prepared medication in the syringe during a short period of time, but this does not explain two hand recapping and suggests other factors such as workload and safety culture [25].

Paul, in his study reported that 12.5% of providers had washed their hands with soap and water before administering an injection; only 7/3% of nursing staff had used sterile gloves during injections [31], less than related results in our study. The necessity for hand hygiene in injections will differ depending on whether there was contact with soil, blood or body fluids. Single-use gloves may be indicated when performing intravenous device insertions and infusions [24]. This procedures are common in the ORs and Lower values for those can be attributed to a knowledge gap or an excessive workload [33, 34].

Results of a study by Gounder showed that not using a new needle and syringe for each new patient or to access medication vials was observed in 3% and 28% of cases, respectively [35]. In this regard results of the present study were acceptable. Not using a new needle could justify limiting factors such as excessive workload and shortage of a supply.

Maintaining an adequate supply of single-use devices is essential to enable providers to use new devices each time they perform a procedure. In our study providers declared stock-outs of some supplies during the last 6 months.

Giard reported a 94.5% compliance rate “always" by HCWs for changing gloves between patients [36]. Hutin declared factors of unsafe injection practice as; a shortage of single use injection devices, insufficient awareness of the risk of HIV infection from unsafe injections, and weakness in waste management sharps waste management [37]. In the present study providers used new gloves in 37% of injections.

Omorogbe reported that 58.2% of respondents had NSIs [29]. This amount included 53% of providers during the previous 12 months[30], similar to our rate. Less than half of our respondents knew that hepatitis B, C, and HIV can all be transmitted via unsafe injection, which is much lower than the rate reported by Vong, et al, who reported that 90% were aware of this risk [30, 31], indicating a knowledge gap.

In Omorogbe’s study knowledge was significantly influenced by gender, and work experience of nurses [29], different from our findings. In this regard observed compliance with requirements was better in ORs B. Work experience of providers was higher in ORs B which could be an effective factor.

Low rate of vaccination against Hepatitis B Virus (HBV) was reported by providers with different coverage between them. Reported rate of HBV vaccination coverage were 70.1%, and 73% for physicians, and nurses in Iran, respectively [38] different from our results in ORs. Batra reported that 49.6% of HCWs received HBV vaccine [39], similar to present study.

In our study reported knowledge of providers about blood borne diseases was also modest like their behaviors in receiving hepatitis B vaccine. Adherence to universal precautions, such as safe needle disposal and wearing gloves during phlebotomy are weak among HCWs in developing countries [40–41].

Lack of enough Knowledge about blood borne diseases could be the reason for not being vaccinated. Other possible reasons are workload or efficacy of HBV from the point of view of providers.

5. Conclusions

The study revealed that in ORs at selected center, some of the WHO guidelines about safe injection procedures were well carried out (dedicated table for injections and use of sterile disposable syringe) while other safe injection practices were unsatisfactorily implemented (no recapping, no use of disposal bins for sharps and no receiving complete doses of Hepatitis B vaccinations among providers). The important point of the study was that the knowledge of staff was acceptable but their actual practices were unsafe.

It is suggested to implement audits for safe injections, provide safer supplies e.g. auto-disable syringes, and Hepatitis B vaccine with complete doses to all injection providers in ORs. Finally, it seems further study is needed to find probable system or human problems in this regard.

Supporting information

Acknowledgments

Thanks University Vice Chancellor of Research and Technology, and authorities that helped us in correspondence and conducting the project. Special thank to experts and trainers of student nurse anesthetists in selected teaching center for collecting observation data.