Q: I was always told back when I was a nursing student, that if you’ve just removed the flip cap from a vial, the vial rubber port is sterile and does not need to be disinfected prior to access. So I just insert the syringe to withdraw the medication. For vials already opened, I do swab with alcohol prior to use. Should I be swabbing the vial rubber port even if I have just removed the flip cap covering? (signed: an old nurse but not as old as Florence)

A:  Thank you for your question.  Please know that you are not the only one who has been under the impression that the pop off caps (or flip cap) on vials keep the vial diaphragm (rubber port) sterile. And as such, when the cap is popped off, many nurses do not disinfect the diaphragm before inserting the needle to withdraw the medication. Sad to say there are still many nurses and other healthcare providers who believe this as true.

Since you asked, here’s the answer.

• The Association of Practitioners in Infection Control and Epidemiology (APIC) states in its position paper entitled: Safe Injection, Infusion and Medication Vial Practices in Healthcare – Cleanse the access diaphragm of vials using friction and a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab. Allow the diaphragm to dry before inserting any device into the vial.  (source: click here)

• Institute for Safe Medication Practices (ISMP) in its Safe Practice Guidelines for Adult IV Push Medications publication explains:  the “pop-off” vial caps from manufacturers are considered “dust covers” and are not intended to maintain sterility of the vial diaphragm or access point. Thus, the diaphragm must always be disinfected after removing the cap of a new vial. (source: click here)

And while we are talking about “vials”…about the open vials you mentioned -please keep these APIC recommendations in mind.

• Always follow the manufacturer’s instructions for storage and use.
• Use single-use or single-dose vials whenever possible.
• Always use a sterile syringe and needle/cannula when entering a vial. Never enter a vial with a syringe or needle/cannula that has been used on a patient.
• Cleanse the access diaphragm of vials using friction and 70% alcohol or other antiseptic. Allow to dry before inserting a device into the vial.
• Discard single-dose vials after use. Never use them again for another patient.
• If a multidose vial must be used, it should be used for a single patient whenever possible. The risk of transmission posed by inappropriate handling of multi-dose vials has been clearly demonstrated and mandates a practice of one vial per one patient whenever possible. Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient.
• Keep multidose vials away from the immediate patient environment.
• Never store vials in clothing or pockets.
• Use filter needles to withdraw solution from an ampule.
• Never pool or combine leftover contents of vials for later use.
• Never leave a needle, cannula, or spike device inserted into a medication vial rubber stopper because it leaves the vial vulnerable to contamination.
• Dispose of opened multidose medication vials 28 days after opening, unless specified otherwise by the manufacturer, or sooner if sterility is questioned or compromised.
• Exception to 28 day disposal of opened multidose vials: The CDC Immunization
  Program states opened multidose vaccines are to be discarded per manufacturer’s
  expiration date or sooner if sterility is questioned or compromised.
• Date opened multidose vials to reflect date opened and/or date of expiration. An
  organization may choose to establish a system wide opened multidose discard schedule, i.e., one date a month established to discard all opened multidose vials no matter when the vial was opened during the month.
• Inspect vials and discard if sterility has been, or is thought to be compromised.
  Examine the vial for any particulate matter, discoloration or turbidity. If present, do not use and discard immediately. All vials used during an emergency should be discarded as sterility cannot be guaranteed

Thanks again and please share this info with other nursing colleagues so we can all improve our practice. (Florence will be happy)