VA National Center for Patient Safety - Patient Safety Alerts and Advisories

United States Department of Veterans Affairs

VHA Patient Safety Alerts and Advisories

Note: This is not a complete listing of VA Patient Safety Alerts and Advisories.
Please see Safety Topics, Topics in Patient Safety (TIPS) Newsletters, and view PowerPoint: Information on Research Databases for additional information.

NCPS Patient Safety Alert and Patient Safety Advisory Development Process

2013 Alerts and Advisories | 2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001 | 2000

2013 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
January 24, 2013	Alert	International Normalized Ratio (INR) values may display incorrectly in VistA/CPRS Anticoagulation Management Tool (AMT) software AL13-05
January 15, 2013	Alert	Incorrect eye surgery adverse events in Veterans Health Administration facilities AL13-03
January 14, 2013	Alert	Multi-Dose Pen Injectors AL13-04

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2012 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
November 15, 2012	Alert	Increased risk of metabolic alkalosis with acetate-containing dialysis acid concentrates that can cause cardiac arrest, arrhythmias and low blood pressure in dialysis patients AL13-02
October 2, 2012	Alert	High vacuum/high flow suction devices, used inappropriately, have resulted in patient injuries and death AL13-01
May 16, 2012	Alert	Certain lots of Ethicon HARMONIC® HPBLUE and HP054 hand pieces are not compatible with the Ethicon HARMONIC® Generator Model 300 (GEN04) AL12-08
April 10, 2012	Alert	Incorrect Patient Information Displayed in VA’s Computerized Patient Record System (CPRS) v28 AL12-07
April 9, 2012	Advisory	Plastic cards can be used to disable locks in inpatient mental health and Emergency Department (ED) settings treating patients who have the potential for unpredictable or unsafe behavior (e.g., violence, suicide, etc.) and are not on 1:1 observation AD12-02
March 22, 2012	Advisory	Disassembly of wheelchairs in inpatient mental health and emergency department (ED) settings treating patients who have the potential for unpredictable or unsafe behavior (e.g., violence, suicide, etc.) and are not on 1:1 observation AD12-01
February 23, 2012	Alert	Electronic Order Check(s) may not trigger appropriately for drug-allergy interactions due to updates to drug class files in Veterans Health Information Systems and Technology Architecture (VistA)/ Computerized Patient Record System (CPRS) AL12-04* The software referenced in AL12-04 includes VA Computerized Patient Record System (CPRS) v1.0.28.24, Veterans Health Information Systems and Technology Architecture (VistA) Inpatient Medication Package v5.0, VistA Outpatient Pharmacy Package v7.0, and VistA Adverse Reaction Tracking v4.0.
February 10, 2012	Alert	Issues identified with Identity Management in commercial Clinical Information Systems/Anesthesia Record Keeping (CIS/ARK) systems in use at VA facilities. AL12-02
February 9, 2012	Alert	Epinephrine, Phenylephrine, and other High Alert Medication Safety in the Operating and other High Alert Medication Safety in the Operating Room AL12-03* *This Patient Safety Alert AL12-03 replaces and supersedes Patient Safety Advisory AD10-03 issued August 2, 2010.

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2011 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
December 19, 2011	Alert	Software upgrade to resolve Bayer Viterion V100 BGM Home Telehealth hub device not transmitting all of Roche Accu-Chek Aviva blood glucose meters' data via Roche infrared peripheral. Replaces and supersedes Patient Safety Alert AL11-03 issued April 27, 2011 AL12-01 AL12-01 FAQs Revised 1/5/2012
September 22, 2011	Advisory	Some plastic items can cause harm in mental health units treating actively suicidal patients and other areas treating or holding suicidal patients who are not on 1:1 observation AD11-02
September 12, 2011	Alert	Look-Alike Hemodialysis Solutions AL11-09
June 28, 2011	Alert	Potential anchor points for hanging in mental health units treating actively suicidal patients and other areas treating or holding suicidal patients that are not on 1:1 observation (e.g., psychiatric holding areas in emergency departments) AL11-08
June 28, 2011	Alert	Furniture floor guards in mental health units treating actively suicidal patients and other areas treating or holding suicidal patients that are not on 1:1 observation (e.g., psychiatric holding areas in emergency departments) AL11-07
June 28, 2011	Alert	Walker used to barricade a sleeping room door on a locked inpatient mental health unit treating currently suicidal patients AL11-06
April 8, 2011	Alert	Use of elastic-hemmed fitted bed sheets in mental health units and other units holding or treating actively suicidal patients AL11-02 FAQS for AL11-02 Revised 4/19/2011

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2010 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
October 25, 2010	Alert	Standardized Process for Insulin Orders when used in Patient Controlled Insulin Pumps AL11-01* The software referenced in AL11-01 includes VA Computerized Patient Record System (CPRS) v1.0.27.90, Bar Code Medication Administration (BCMA) v3.0.32.47, and uses Veterans Health Information Systems and Technology Architecture (VistA) Inpatient Medication Package v5.0.
July 7, 2010	Alert	Hepatitis C virus (HCV) testing using Novartis Chiron RIBA HCV 3.0 Strip Immunoblot Assay (SIA) reagents AL10-14
July 7, 2010	Alert	Redsense® Dialysis Alarm for Patients Undergoing Needle Access Procedures AL10-13 FAQS for AL10-13 Revised 10/29/2010
May 13, 2010	Alert	Philips IntelliVue Non Invasive Blood Pressure (NIBP) monitors may display only Mean Arterial Pressure (MAP) results: Models MP20/30/40/50/60/70/80/90 AL10-11
May 4, 2010	Alert	Hospital-grade power cords, manufactured by Electri-Cord and sold to medical equipment manufacturers AL10-10
March 22, 2010	Alert	Ceiling mounted patient lift installations AL10-07
February 17, 2010	Advisory	Misidentification of patient resulting in delay of surgery AD10-01
February 3, 2010	Alert	Fresenius HemaClip used during dialysis AL10-05

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2009 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
December 14, 2009	Alert	Possible blood contamination in hemodialysis machines AL10-04
October 6, 2009	Alert	Attempted hanging from a door in a locked mental health unit AL10-03
October 1, 2009	Alert	Glucose Monitoring Test Strips that utilize Glucose Dehydrogenase Pyrroloquinoline Quinone (GDH-PQQ) methodology may give falsely elevated glucose results AL10-01
September 2, 2009	Alert	Operable exterior windows in locked inpatient mental health units AL09-25
August 6, 2009	Alert	Medtronic SynchroMed II Implantable Drug Infusion Pump; Models: 8637-20 and 8637-40 AL09-24
July 10, 2009	Advisory	Alarms on bedside physiological monitors AD09-09
June 16, 2009	Alert	Philips IntelliVue G1/G5 Anesthesia Gas Modules: Model Numbers M1013A and M1019A and Dräger Apollo Anesthesia Machines and Multigas Monitor: Model SCIO AL09-23
June 8, 2009	Alert	Physician Advisory issued by Medtronic Inc. on subsets of: Kappa 600/700/900 series dual chamber and single chamber pacemakers and Sigma 100/200/300 series dual chamber and single chamber cardiac pacemakers AL09-22
May 4, 2009	Alert	Arjo Carendo Shower Chair Model BIB 2003-01 or BIB2003-01KT AL09-21
April 22, 2009	Alert	Transvaginal Placement of Surgical Mesh AL09-20
April 3, 2009	Alert	CPRS – Changing Medication Schedule may Leave Incorrect Medication Administration Times AL09-19
March 24, 2009	Alert	AEDPlus Public Access Automated External Defibrillators (AEDs), manufactured by Zoll. AL09-17
March 5, 2009	Alert	Cylinder Valve Explodes from Oxygen Cylinder supplied with Rotarex/Ceodeux Post Type Cylinder Valve AL09-16
March 3, 2009	Alert	Medication Safety- Insulin U-500 Safety Enhancements AL09-15
February 20, 2009	Alert	Medtronic InFuse Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion AL09-13
February 19, 2009	Advisory	Cardinal Health’s Alaris System Infusion Pumps AD09-07

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2008 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
December 30 , 2008	Advisory	Suicide attempt in the Emergency Room (ER) AD09-05
December 22 , 2008	Alert	Improper set-up and reprocessing of flexible endoscope tubing and accessories AL09-07
November 20, 2008	Alert	Maxi Move patient lifts with "Lock and Load" system (Combi Hanger): Manufactured by Arjo between November 2005 and April 2008 AL09-06
October 27, 2008	Alert	Baxter Single Strength Dosing Card for BREVIBLOC Premixed Injection (esmolol HCl) 2,500 mg/250 mL (10 mg/mL) Ready-to-use-Bags, 250 mL bags AL09-03
October 24, 2008	Alert	Medtronic Neuromodulation Sutureless Connector Catheters used with SynchroMed and IsoMed implantable infusion pumps: INDURA One-Piece (1P) Intrathecal Catheters, Model 8709SC Intrathecal Catheters, Model 8731SC Sutureless Pump Connector Revision Kit, Model 8578 Intrathecal Catheter Pump Segment Revision Kit, Model 8596SC AL09-02
October 21, 2008	Advisory	Methicillin-resistant Staphylococcus aureus (MRSA) contamination in an orthopedic clinic room AD09-03
October 21, 2008	Advisory	Bleeding episodes during dialysis AD09-02
October 10, 2008	Alert	Shower curtains in locked mental health units AL09-01
March 31, 2008	Alert	Improper reprocessing of flexible endoscope biopsy valves AL08-13
March 12, 2008	Alert	STERIS C1160 Universal Flexible Processing Trays used with the STERIS System 1 Sterile Processing Systems AL08-11
January 25, 2008	Alert	Implant orientation of Implantable Cardioverter Defibrillators (ICDs) and Cardiac Resynchronization Therapy Devices (CRT-Ds) manufactured by Boston Scientific Corporation’s Cardiac Rhythm Management Division, previously under the name Guidant. AL08-07

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2007 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
December 21, 2007	Alert	FDA CLASS II recall of Boston Scientific Corporation's Cardiac Rhythm Management Division (previously called Guidant) Implantable Cardiac Defibrillators (ICDs) and Cardiac Resynchronization Therapy Defibrillators (CRT-Ds). AL08-06
December 7, 2007	Advisory	Positive displacement, needle-free intravascular connector valves AD08-01
November 29, 2007	Alert	Model 8100 infusion pump modules shipped before September 27, 2007; a component of the Alaris Medley infusion pump system, distributed by Cardinal Health. AL08-04
October 25, 2007	Alert	Sprint Fidelis® Defibrillation Leads, manufactured by Medtronic AL08-02
October 23, 2007	Alert	Medtronic SynchroMed EL implantable infusion pump; models: 8626-10, 8626L-10, 8626-18, 8626L-18, 8627-10, 8627L-10, 8627-18, 8627L-18. AL08-01
April 18, 2007	Alert	Boston Scientific Corporation's Cardiac Rhythm Management Division (previously called Guidant) recall of Implantable Cardiac Defibrillators (ICDs) and Cardiac Resynchronization Therapy Defibrillators (CRT-Ds). AL07-07
February 16 , 2007	Alert	Privacy curtains in locked mental health wards AL07-04
February 14, 2007	Advisory	Daylight Savings Time (DST) changes AD07-04
January 31, 2007	Advisory	Reprocessing of resectoscope system’s working elements AD07-03
January 8, 2007	Advisory	Gemini PC series infusion pumps manufactured by Alaris, formerly IMED AD07-01

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2006 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
August 30, 2006	Alert	All models of Alaris® SE infusion pumps - formerly the Signature Edition® Infusion System. Alaris is a subsidiary of Cardinal Health, Inc. AL06-16
July 24, 2006	Alert	Sealed, lead-acid batteries for external defibrillators supplied by non-OEM (Original Equipment Manufacturer) or second source suppliers. Second source suppliers include Alpha Source, Anybattery, R&D; Batteries and Unipower, among others. AL06-15
June 28, 2006	Alert	Boston Scientific/Guidant Recall AL06-14
April 6, 2006	Alert	Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions AL06-12
April 3, 2006	Alert	Transrectal ultrasound transducer assembly, Models 8808 and 8551, manufactured by B-K Medical Systems, Inc., Wilmington, MA AL06-11
February 8, 2006 Attachment A Updated 8/11/06	Alert	Cessation of Topical Spray Benzocaine Usage to Anesthetize the Surfaces of the Nasopharynx, Oropharynx, Laryngotracheal Region and Airway AL06-09
January 10, 2006	Advisory	Ipump Pain Management System, APII Infusion Pump and PCAII Infusion Pump, manufactured by Baxter Healthcare Corporation. AD06-03
January 9, 2006	Alert	Physician Advisory issued by Medtronic Inc. on the Sigma Series single and dual chamber pacemakers (SD203, SD303, SDR203, SDR303, SDR306, SVDD303, SS103, SS106, SS203, SS303, SSR203, SSR303, SSR306, SVVI103) AL06-08

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2005 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
December 21, 2005	Alert	Injector connector relays on patient tables manufactured by Philips Medical, table models AD5 and AD6 used with the Integris, Integris Allura and Allura Xper x-ray systems.) AL06-06
November 1, 2005	Alert	Heat maintainers for Stellant CT Injector Systems, manufactured by MEDRAD, Inc. Part numbers for the heat maintainers are 3007871, 3007872, 3009707 and 3009708. (Note: Part numbers for the Stellant injector systems are 3007301, 3010432, 3007300 and 3010091.) AL06-04
June 8, 2005	Alert	Guidant Model 1861 Ventak Prizm 2 DR, Implantable Cardioverter-Defibrillators (ICD) manufactured before November 2002 AL05-13
May 31, 2005	Alert	Blood Glucose Monitors (Glucometers), models OneTouch, Ultra, InDuo, and OneTouch FastTake manufactured by LifeScan, Inc. AL05-11
March 29, 2005	Alert	Enclosed Bed systems manufactured by Vail Products Inc, models: 500, 1000, and 2000. AL05-09
February 28, 2005	Alert	Louvered heating, ventilating and air conditioning (HVAC) grilles in locked Behavioral Health Units. AL05-06
January 12, 2005	Alert	Nellcor pulse oximeters, model 595 and limited quantities of models 395, 295 and 290 Nellcor 595 Alert
January 10, 2005	Advisory	Depression Screening for Veteran Patients Recently Separated from Active Military Duty Depression Screening Advisory

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2004 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
November 9, 2004	Advisory	Electro-magnetic Interference (EMI) from the use of two-way hand held radios/ walkie-talkies in close proximity to medical devices. EMI Advisory
October 21, 2004	Advisory	ALARIS (IMED) Gemini Infusion Pumps Alaris Gemini Advisory
July 2, 2004	Alert	Failure of medical alarm systems using paging technology to notify clinical staff Alarm Paging Alert
June 2, 2004	Alert	Minor Surgery/Exam lights: CoolSpot™ and Outpatient® Fleximount™ Single Ceiling and Track Mount with Single Trolley manufactured by Burton Medical before August 2000. Burton Lights Alert
April 28, 2004	Alert	Implantable Cardioverter Defibrillators (ICD) manufactured by Medtronic Medtronic ICD Alert
April 28, 2004	Advisory	Drug File View from CPRS CPRS Drug File Advisory
April 5, 2004	Alert	Oxygen Utility System Oxygen Utility System Alert
February 13, 2004	Alert	Connectors for Sterilization of all Gastrointestinal Fiberoptic Endoscopes

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2003 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
November 4, 2003	Alert	J&J; Cordis CypherTM Sirolimus-Eluting Coronary Stent
July 21, 2003	Alert	Soft Skin protective sleeve
July 14, 2003	Alert	Power cords for Hill-Rom Century+ electric beds
June 18, 2003	Alert	Decimal point display - Abbott APM II pump
June 18, 2003	Alert	In-line air filter requirement for Abbott Pumps
March 6, 2003	Advisory	Olympus EXERA™ Gastrointestinal Endoscopes

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2002 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
September 30, 2002	Advisory	Cochlear Implant Risk
July 22, 2002	Advisory	SSCOR Suction Pumps
May 28, 2002	Advisory	ADDENDUM to Advisory for Allegiance Irrigation Kits
February 27, 2002	Advisory	Potential for incorrectly attaching Allegiance Irrigation Kit caps to Foley catheters
January 23, 2002	Alert	Zoll M Series defibrillators and M Series Automated External Defibrillators

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2001 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
August 15, 2001	Advisory	Risperidone oral medication syringe (pipette)
July 13, 2001	Alert	Bed Rail Entrapment For additional information see the 1995 FDA Alert
February 5, 2001	Alert	Magnetic Resonance Imaging (MRI) systems

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2000 Alerts and Advisories

Date Issued	Alert or Advisory	Product - Device Clicking on an alert name will open it in a new window.
January 3, 2000	Alert	Ventilators - All Makes/Models

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