NCPS Patient Safety Alert and Patient Safety Advisory Development Process
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 |
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) *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 *This Patient Safety Alert AL12-03 replaces and supersedes Patient Safety Advisory AD10-03 issued August 2, 2010. |
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 FAQS for AL11-02 Revised 4/19/2011 |
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 *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 |
July 7, 2010 | Alert
|
Redsense® Dialysis Alarm for Patients Undergoing Needle Access Procedures 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 |
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 |
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:
|
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |