BACKGROUND: Unsafe injection practices result in a substantial burden of preventable blood-borne viral disease (BBV). The reasons are complex and include structural, economic and socio-cultural factors. OBJECTIVE: To describe injection-related practices in two rural north Indian health settings including the contextual factor, highlight some of the challenges facing those endeavouring to translate injection safety policies into safe injection practice, and to identify appropriate intervention strategies. METHOD: Qualitative data collection (participant observation and in-depth interviews) in two rural north Indian hospitals with affiliated community-based programmes over a 4-month period. A total of 130 h of observation took place in a range of clinical areas characterized by frequent use of needles and other sharps, and 40 healthcare workers were interviewed. Field notes and interview transcripts were thematically analysed. RESULTS: Managers in these health settings were clearly endeavouring to promote injection safety by implementing the widespread use of disposable needles and syringes and attempting to address the difficult issue of safe healthcare waste management. However, some unsafe practices were still occurring: reuse of syringes (with and without sterilization) was relatively common, and use of multi-dose vials, blood sampling, sterilization and disinfection, and healthcare waste management were sub-optimal in some instances, placing both staff and patients at unnecessary risk of BBV infection. CONCLUSION: Strategies for promoting injection safety are necessary if the risk of nosocomial transmission of BBV diseases via unsafe injection practices in rural north India is to be minimized.