Medication vial coring incidents prompt patient safety concerns

Editor's Note

Safety organizations are raising concerns amid increased reports of improper needle use causing vial coring, leading to potential contamination and patient risk.

Published April 4 by the Anesthesia Patient Safety Foundation (APSF) and ECRI/Institute for Safe Medicine Practices (ISMP), the alert offers interim guidelines to reduce risks associated with medication vial access.

Vial coring—which occurs when a piece of the flexible stopper on a medication vial detaches during needle insertion, potentially contaminating the medication or entering the patient—has long been recognized as a potential issue, but it is more likely with blunt needles. As detailed in the announcement, data supporting best practices for accessing vials is limited despite this risk. The interim guidelines are meant to help alleviate the risk amid the recent surge in reported cases while APSF and ECRI/ISMP work on formal evidence-based recommendations. Interim recommendations include:

• Use sharp needles, ideally with needle guard protection.
• Use smaller-gauge needles when possible (such as opting for 21-gauge rather than 18-gauge).
• Insert the needle at an angle that creates the least resistance to puncture (the announcement notes that there is no consistent evidence to support a specific optimal angle).
• Puncture the vial stopper only once
• Inspect the vial for visible coring before administering the medication.
• Report coring incidents directly to ISMP, including details such as the medication name, manufacturer, lot number, needle type, gauge, and, if possible, photographic evidence of the coring.

Although no documented cases of patient harm from coring have been reported, APSF and ECRI/ISMP stress the potential for significant risk. These interim guidelines currently apply only to needle access of vials with flexible stoppers.