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VHA National Center for Patient Safety

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Alerts and Advisories

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NCPS develops and publishes Patient Safety Alerts and Advisories that concern specific issues relating to equipment, medications, and procedures that might cause harm to patients.

Alerts communicate urgent notices that require immediate and specific action(s) by specific parties by a specified deadline. Advisories communicate recommendations and are more general in nature, and their implementation may be subject to local judgment.

Most alerts and advisories are shared with the public; however, when the information is relevant only to VA employees, those Alerts or Advisories are placed on NCPS’ Intranet site; therefore, this is not a complete list of all Alerts and Advisories.

2018 | 2014 | 2013 | 2012 | 2011 | 2010 | 2009 | 2008 | 2007
2006 | 2005 | 2004 | 2003 | 2002 | 2001 | 2000 |


Date Level Product/Device
2018-03-12 Alert

Use of Thermal Fuses May Reduce the Severity of Fires Involving Home Oxygen Delivery Systems.


Date Level Product/Device
2014-11-08 Alert

Table Tipping Risk with GE Healthcare Infinia Nuclear Medicine Imaging Systems.


Date Level Product/Device
2013-06-07 Alert

GE dual-head gamma cameras: Unintended movement can cause serious injury or death.

Please note: This Patient Safety Alert affects a more comprehensive list of dual-headed gamma cameras than in previous communications. AL 13-08 amended by AL13-08 Addendum and AL 13-08 Addendum #2.

2013-01-15 Alert

Incorrect eye surgery adverse events in Veterans Health Administration facilities


Date Level Product/Device
2012-11-15 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


2012-10-02 Alert

High vacuum/high flow suction devices, used inappropriately, have resulted in patient injuries and death

2012-05-16 Alert

Certain lots of Ethicon HARMONIC HPBLUE and HP054 hand pieces are not compatible with the Ethicon HARMONIC Generator Model 300 (GEN04)

2012-04-10 Alert

Incorrect Patient Information Displayed in VA's Computerized Patient Record System (CPRS) v28

2012-04-09 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

2012-03-22 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

2012-02-10 Alert

Issues identified with Identity Management in commercial Clinical Information Systems/Anesthesia Record Keeping (CIS/ARK) systems in use at VA facilities.


Date Level Product/Device
2011-12-19 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

2011-09-12 Alert

Look-Alike Hemodialysis Solutions

2011-06-28 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)

2011-06-28 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)

2011-06-28 Alert

Walker used to barricade a sleeping room door on a locked inpatient mental health unit treating currently suicidal patients

2011-04-08 Alert

Use of elastic-hemmed fitted bed sheets in mental health units and other units holding or treating actively suicidal patients


Date Level Product/Device
2010-10-25 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.

2010-07-07 Alert

Hepatitis C virus (HCV) testing using Novartis Chiron RIBA HCV 3.0 Strip Immunoblot Assay (SIA) reagents

2010-07-07 Alert

Redsense® Dialysis Alarm for Patients Undergoing Needle Access Procedures

2010-05-13 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

2010-05-04 Alert

Hospital-grade power cords, manufactured by Electri-Cord and sold to medical equipment manufacturers

2010-03-22 Alert

Ceiling mounted patient lift installations

2010-02-17 Advisory

Misidentification of patient resulting in delay of surgery

2010-02-03 Alert

Fresenius HemaClip used during dialysis


Date Level Product/Device
2009-12-14 Alert

Possible blood contamination in hemodialysis machines

2009-10-06 Alert

Attempted hanging from a door in a locked mental health unit

2009-10-01 Alert

Glucose Monitoring Test Strips that utilize Glucose Dehydrogenase Pyrroloquinoline Quinone (GDH-PQQ) methodology may give falsely elevated glucose results

2009-09-02 Alert

Operable exterior windows in locked inpatient mental health units

2009-08-06 Alert

Medtronic SynchroMed II Implantable Drug Infusion Pump; Models: 8637-20 and 8637-40

2009-07-10 Advisory

Alarms on bedside physiological monitors

2009-06-16 Alert

Philips IntelliVue G1/G5 Anesthesia Gas Modules: Model Numbers M1013A and M1019A and Dräger Apollo Anesthesia Machines and Multigas Monitor: Model SCIO

2009-06-08 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

2009-05-04 Alert

Arjo Carendo Shower Chair Model BIB 2003-01 or BIB2003-01KT

2009-04-22 Alert

Transvaginal Placement of Surgical Mesh

2009-03-24 Alert

AEDPlus Public Access Automated External Defibrillators (AEDs), manufactured by Zoll.

2009-03-05 Alert

Cylinder Valve Explodes from Oxygen Cylinder supplied with Rotarex/Ceodeux Post Type Cylinder Valve

2009-02-20 Alert

Medtronic InFuse Recombinant Human Bone Morphogenetic Protein in Cervical Spine Fusion


2009-02-19 Advisory

Cardinal Health’s Alaris System Infusion Pumps


Date Level Product/Device
2008-12-30 Advisory

Suicide attempt in the Emergency Room (ER)

2008-12-22 Alert

Improper set-up and reprocessing of flexible endoscope tubing and accessories

2008-10-27 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

2008-10-24 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

2008-10-21 Advisory

Methicillin-resistant Staphylococcus aureus (MRSA) contamination in an orthopedic clinic room

2008-10-21 Advisory

Bleeding episodes during dialysis

2008-10-10 Alert

Shower curtains in locked mental health units

2008-03-31 Alert

Improper reprocessing of flexible endoscope biopsy valves

2008-03-12 Alert

STERIS C1160 Universal Flexible Processing Trays used with the STERIS System 1 Sterile Processing Systems

2008-01-25 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.


Date Level Product/Device
2007-12-21 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).

2007-12-07 Advisory

Positive displacement, needle-free intravascular connector valves

2007-11-29 Alert

Model 8100 infusion pump modules shipped before September 27, 2007; a component of the Alaris Medley infusion pump system, distributed by Cardinal Health.

2007-10-25 Alert

Sprint Fidelis® Defibrillation Leads, manufactured by Medtronic

2007-10-23 Alert

Medtronic SynchroMed EL implantable infusion pump; models: 8626-10, 8626L-10, 8626-18, 8626L-18, 8627-10, 8627L-10, 8627-18, 8627L-18.

2007-04-18 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).

2007-02-16 Alert

Privacy curtains in locked mental health wards

2007-02-14 Advisory

Daylight Savings Time (DST) changes


2007-01-31 Advisory

Reprocessing of resectoscope system’s working elements


Date Level Product/Device
2006-08-30 Alert

All models of Alaris® SE infusion pumps — formerly the Signature Edition® Infusion System. Alaris is a subsidiary of Cardinal Health, Inc.

2006-07-24 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.

2006-06-28 Alert

Boston Scientific/Guidant Recall

2006-04-06 Alert

Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions

2006-04-03 Alert

Transrectal ultrasound transducer assembly, Models 8808 and 8551, manufactured by B-K Medical Systems, Inc., Wilmington, MA

2006-02-08 Alert

Cessation of Topical Spray Benzocaine Usage to Anesthetize the Surfaces of the Nasopharynx, Oropharynx, Laryngotracheal Region and Airway

Attachment A Updated 8/11/06

2006-01-10 Advisory

Ipump Pain Management System, APII Infusion Pump and PCAII Infusion Pump, manufactured by Baxter Healthcare Corporation.

2006-01-09 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)


Date Level Product/Device
2005-12-21 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.)

2005-06-08 Alert

Guidant Model 1861 Ventak Prizm 2 DR, Implantable Cardioverter-Defibrillators (ICD) manufactured before November 2002

2005-05-31 Alert

Blood Glucose Monitors (Glucometers), models OneTouch, Ultra, InDuo, and OneTouch FastTake manufactured by LifeScan, Inc.

2005-03-29 Alert

Enclosed Bed systems manufactured by Vail Products Inc, models: 500, 1000, and 2000.

2005-02-28 Alert

Louvered heating, ventilating and air conditioning (HVAC) grilles in locked Behavioral Health Units.

2005-01-12 Alert

Nellcor pulse oximeters, model 595 and limited quantities of models 395, 295 and 290

2005-01-10 Advisory

Depression Screening for Veteran Patients Recently Separated from Active Military Duty


Date Level Product/Device
2004-11-09 Advisory

Electro-magnetic Interference (EMI) from the use of two-way hand held radios/ walkie-talkies in close proximity to medical devices.

2004-07-02 Alert

Failure of medical alarm systems using paging technology to notify clinical staff

2004-04-28 Alert

Implantable Cardioverter Defibrillators (ICD) manufactured by Medtronic

2004-04-28 Advisory

Drug File View from CPRS

2004-04-05 Alert

Oxygen Utility System

2004-02-13 Alert

Connectors for Sterilization of all Gastrointestinal Fiberoptic Endoscopes


Date Level Product/Device
2003-11-04 Alert

J&J Cordis CypherTM Sirolimus-Eluting Coronary Stent

2003-07-21 Alert

Soft Skin protective sleeve

2003-06-18 Alert

Decimal point display - Abbott APM II pump

2003-06-18 Alert

In-line air filter requirement for Abbott Pumps

2003-03-06 Advisory

Olympus EXERA™ Gastrointestinal Endoscopes


Date Level Product/Device
2002-09-30 Advisory

Cochlear Implant Risk

2002-07-22 Advisory

SSCOR Suction Pumps

2002-05-28 Advisory

ADDENDUM to Advisory for Allegiance Irrigation Kits

2002-02-27 Advisory

Potential for incorrectly attaching Allegiance Irrigation Kit caps to Foley catheters

2002-01-23 Alert

Zoll M Series defibrillators and M Series Automated External Defibrillators


Date Level Product/Device
2001-08-15 Advisory

Risperidone oral medication syringe (pipette)

2001-07-13 Alert

Bed Rail Entrapment

2001-02-05 Alert

Magnetic Resonance Imaging (MRI) systems


Date Level Product/Device
2000-01-03 Advisory