The Joint Commission issued a sentinel event alert to prevent infection from misuse of vials in hospitals. Misusing vials caused blood-borne pathogen outbreaks and associated infections, such as hepatitis B and C, meningitis and epidural abscesses in both inpatient and outpatient settings, according to a report. There were 49 outbreaks since 2001, requiring 150,000 to undergo testing after exposure to unsafe injections. Healthcare practitioners admitted to using vials for multiple patients, using the same syringe to re-enter a vial numerous times for the same patient or reusing a syringe to obtain an additional dose from a multiple-dose vial then leaving for use on another patient. The report calls for healthcare professionals to develop and implement evidence-based, organization-wide standardized policy and procedures for preventing misuse of vials. Alert