National Center for Patient Safety
VHA Patient Safety Alerts and Advisories
Note: This list of alerts is not complete. Unless otherwise noted, all documents are in MS Word format.
Please see Safety Topics, Topics in Patient Safety (TIPS) Newsletters, and view PowerPoint: Information on Research Databases for additional information.
2008 Alerts and Advisories |
2007 Alerts and Advisories |
2006 Alerts and Advisories |
2005 Alerts and Advisories |
2004 Alerts and Advisories |
2003 Alerts and Advisories |
2002 Alerts and Advisories |
2001 Alerts and Advisories |
2000 Alerts and Advisories
Date Issued |
Alert or Advisory |
Product - Device |
December 30 , 2008 |
Advisory |
Suicide attempt in the Emergency Room (ER)
PDF Version |
December 22 , 2008 |
Alert |
Improper set-up and reprocessing of flexible endoscope tubing and accessories
PDF Version |
November 20, 2008 |
Alert |
Maxi Move patient lifts with "Lock and Load" system (Combi Hanger): Manufactured by Arjo between November 2005 and April 2008
PDF Version |
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
PDF Version |
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
PDF Version |
October 21, 2008 |
Advisory |
Methicillin-resistant Staphylococcus aureus (MRSA) contamination in an orthopedic clinic room
PDF Version |
October 21, 2008 |
Advisory |
Bleeding episodes during dialysis
PDF Version |
October 10, 2008 |
Alert |
Shower curtains in locked mental health units
PDF Version |
March 31, 2008 |
Alert |
Improper reprocessing of flexible endoscope biopsy valves
PDF Version |
March 12, 2008 |
Alert |
STERIS C1160 Universal Flexible Processing Trays used with the STERIS
System 1 Sterile Processing Systems
PDF Version |
February 29, 2008 |
Alert |
Expanded Recall of Baxter Heparin Products
PDF Version |
February 19, 2008 |
Alert |
Baxter - Allergic Reactions to Heparin Sodium
PDF Version |
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.
PDF Version |
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Date Issued |
Alert or Advisory |
Product - Device |
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).
PDF Version |
December 7, 2007 |
Advisory |
Positive displacement, needle-free intravascular connector valves
PDF Version |
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.
PDF Version |
October 25, 2007 |
Alert |
Sprint FidelisĀ® Defibrillation Leads, manufactured by Medtronic
PDF Version |
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.
PDF Version |
May 18, 2007 |
Alert |
Shelhigh, Inc. implantable medical products
PDF Version |
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).
PDF Version |
February 16 , 2007 |
Alert |
Privacy curtains in locked mental health wards
PDF Version Attachment 1 |
February 14, 2007 |
Advisory |
Daylight Savings Time (DST) changes
PDF Version |
January 31, 2007 |
Advisory |
Reprocessing of resectoscope system’s working elements
PDF Version |
January 8, 2007 |
Advisory |
Gemini PC series infusion pumps manufactured by Alaris,
formerly IMED
PDF Version |
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Date Issued |
Alert or Advisory |
Product - Device |
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.
PDF Version |
August 24 , 2006 |
Advisory |
Shutdown of Donor Referral Services (DRS) Tissue Harvesting Co by FDA
PDF Version |
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.
PDF Version |
June 28, 2006 |
Alert |
Boston Scientific/Guidant Recall
PDF Version |
May 8 , 2006 |
Advisory |
Oxygen Regulator Fires Resulting from Incorrect Use of CGA 870 Seals
PDF Version |
April 6, 2006 |
Alert |
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions
PDF Version |
April 3, 2006 |
Alert |
Transrectal ultrasound transducer assembly, Models 8808 and 8551, manufactured by B-K Medical Systems, Inc., Wilmington, MA
PDF Version |
March 6, 2006 |
Alert |
Alaris IV Tubing sets, including commonly used 72023E and 72033E sets, manufactured by Cardinal Health, Alaris Products
PDF Version |
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
PDF Version
|
January 10, 2006 |
Advisory |
Ipump Pain Management System, APII Infusion Pump and PCAII Infusion Pump, manufactured by Baxter Healthcare Corporation.
PDF Version |
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)
PDF Version
|
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Date Issued |
Alert or Advisory |
Product - Device |
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.)
PDF Version
|
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.)
PDF Version | Word Version |
October 5, 2005 |
Alert |
Olympus 180 series endoscopes and Steris Quick Connects
PDF Version | Word Version |
June 22, 2005 |
Alert |
Smiths Medical, Fast Flow Fluid Warmer Models 250, 500 and 1000
PDF Version | Word Version |
June 8, 2005 |
Alert |
Guidant Model 1861 Ventak Prizm 2 DR, Implantable Cardioverter-Defibrillators (ICD) manufactured before November 2002
PDF Version | Word Version |
May 31, 2005 |
Alert |
Blood Glucose Monitors (Glucometers), models OneTouch, Ultra, InDuo, and OneTouch FastTake manufactured by LifeScan, Inc.
PDF Version |
May 12, 2005 |
Alert |
Laerdal CM-100 Heartstart Adapter Cables
PDF Version |
March 29, 2005 |
Alert |
Enclosed Bed systems manufactured by Vail Products Inc, models: 500, 1000, and 2000.
PDF Version | Word Version |
February 28, 2005 |
Alert |
Louvered heating, ventilating and air conditioning (HVAC) grilles in locked Behavioral Health Units.
PDF Version | Word Version |
January 12, 2005 |
Alert |
Nellcor pulse oximeters, model 595 and limited quantities of models 395, 295 and 290
PDF Version | Word Version |
January 10, 2005 |
Advisory |
Depression Screening for Veteran Patients Recently Separated from Active Military Duty
PDF Version | Word Version |
January 6, 2005 |
Alert |
Fire Response and Planning
PDF Version | Word Version |
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Date Issued |
Alert or Advisory |
Product - Device |
November 17, 2004 |
Alert |
Automated External Defibrillators (AED) manufactured by Access Cardiosystems, Inc. -- failure to operate correctly
PDF Version | Word Version |
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.
PDF Version | Word Version |
October 21, 2004 |
Advisory |
ALARIS (IMED) Gemini Infusion Pumps
PDF Version | Word Version |
August 12, 2004 |
Alert |
Shiley Tracheosoft XLT Extended Length Tracheostomy Tube and Cannula FDA Class I Recall
PDF Version | Word Version |
July 22, 2004 |
Alert |
Boston Scientific Stent System Recall
PDF Version | Word Version |
July 8, 2004 |
Advisory |
Tubing separation of Edwards Lifesciences VAMP Plus® Disposable Pressure Transducers Monitoring Kits
PDF Version | Word Version |
July 2, 2004 |
Alert |
Failure of medical alarm systems using paging technology to notify clinical staff
PDF Version | Word Version |
June 28, 2004 |
Alert |
DeRoyal ReliaFlex™ Suction Canisters with Liners
PDF Version
|
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.
PDF Version | Word Version |
May 19, 2004 |
Alert |
Class I Recall of Medtronic MiniMed Paradigm® Quick-set® Plus Infusion Sets
PDF Version | Word Version |
April 28, 2004 |
Alert |
Implantable Cardioverter Defibrillators (ICD) manufactured by Medtronic
PDF Version | Word Version |
April 28, 2004 |
Advisory |
Drug File View from CPRS PDF Version | Word Version |
April 5, 2004 |
Alert |
Oxygen Utility System PDF Version | Word Version |
March 19, 2004 |
Alert |
Propharma Twice-A-Day Nasal Spray Recall PDF Version | Word Version |
February 13, 2004 |
Alert |
Connectors for Sterilization of all Gastrointestinal Fiberoptic Endoscopes |
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Date Issued |
Alert or Advisory |
Product - Device |
November 7, 2003 |
Alert |
Counterfeit PROLENE |
November 7, 2003 |
Alert |
Roche Diagnostics Corp. CoaguChek PT Test Strips |
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 |
May 5, 2003 |
Alert |
ACCU-CHEK® Glucose Test Strips |
March 18, 2003 |
Alert |
Counterfeit Drugs labeled as PROCRIT® |
March 6, 2003 |
Advisory |
Olympus EXERA Gastrointestinal Endoscopes |
February 19, 2003 |
Alert |
Zoll AED, Public Access Defibrillator
Urgent Device Correction for Zoll AED (Letter) |
January 7, 2003 |
Alert |
Kendall Connection Tubing Sets |
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Date Issued |
Alert or Advisory |
Product - Device |
November 25, 2002 |
Alert |
Power cords used with GE Dinamap Vital Signs Monitors |
November 19, 2002 |
Alert |
4341B Thoracentesis Catheters |
September 30, 2002 |
Advisory |
Cochlear Implant Risk |
September 13, 2002 |
Alert |
Blood Tubing for Dialysis - PDF version | MSWord version
(includes both NCPS Alert and FDA News Release)
FDA News Release re:Blood Tubing for Dialysis |
July 22, 2002 |
Advisory |
SSCOR Suction Pumps |
May 30, 2002 |
Alert |
Philips Viridia Information Centers |
May 28, 2002 |
Advisory |
ADDENDUM to Advisory for Allegiance Irrigation Kits |
May 14, 2002 |
Alert |
Baxter Colleague Infusion Pumps |
March 8, 2002 |
Alert |
Bronchoscopes Manufactured by Olympus America |
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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