# Development of a Medical Device in Response to a Fatal Self-Injection of Non-prescribed Opioids: A Case Report

## TL;DR

A patient with opioid use disorder fatally self-injected opioids into a medical catheter, highlighting the need for devices to prevent such incidents.

## Contribution

The paper introduces the need for a medical device to prevent self-injection of non-prescribed substances into vascular access devices.

## Key findings

- There are no commercially available devices to prevent self-injection into vascular access devices.
- A patient's fatal overdose revealed the risks faced by patients who inject drugs in medical settings.
- Formal reporting mechanisms are needed for incidents involving self-injection into vascular access devices.

## Abstract

Patients who inject drugs (PWID) pose unique challenges in their medical care due to risks of increased infection and overdose. There are no known commercially available devices to prevent patients from self-injecting non-prescribed substances into vascular access devices (VADs). A patient in the emergency department (ED) of a midsized suburban hospital self-injected an opioid in the ED restroom after the placement of a vascular catheter by the nursing staff as part of her ED care. Despite precautions taken for a patient with a known opioid use disorder (OUD) and a history of self-injecting non-prescribed substances into VADs, the patient suffered a self-induced fatal overdose. PWID are at significant risk of self-injection when requiring intravenous medications as part of their medical care. This case highlighted the need for formal reporting for patients who self-inject non-prescribed substances into VADs. It revealed a lack of medical devices to help providers ensure that PWID cannot access their medical devices when intravenous therapy is indicated.