CHPSO patient safety alert supplement—Air mattress settings change after being unplugged
November 18, 2010

This supplement to the original alert serves as a reminder to clinicians that they should always check and recalibrate air mattress settings to the patient’s settings when reconnecting. Mattresses, when unplugged, may revert to a default setting.Additionally, though not mentioned in the first alert, on occasion caregivers may use a mattress control unit for a new patient without remembering to change the settings that were used for the prior patient.


CHPSO patient safety alert—Large Alcohol Prep Pad, Swab and Swabsticks recall
January 6, 2011

Due to the broad scope of the recall, we felt it was important to distribute this alert. Note that the product may be labeled with the name of the distributor rather than the manufacturer (“Triad”).Other names used were: Cardinal Health, PSS Select, VersaPro, Boca/ Ultilet, Moore Medical, Walgreens, CVS and Conzellin.


CHPSO patient safety alert—Large Recall of Povidine Iodine Prep Pads
March 21, 2011

H & P Industries, Inc., a manufacturer of over-the-counter products, is voluntarily recalling all Povidine Iodine Prep Pads due to concerns of contamination with the pathogenic bacterium Elizabethkingia meningoseptica. Use of contaminated Povidine Prep Pads could lead to life-threatening infections, especially in at-risk populations, including neonates, immune suppressed patients and surgical patients. Treatment options are limited for Elizabethkingia meningoseptica infections.


CHPSO patient safety alert supplement—H&P Industries and Triad Shut Down
April 5, 2011

US Marshals raided H&P Industries, which makes alcohol wipes and other products distributed by Triad Group. This company was the source of several recent large-scale recalls and CHPSO Patient Safety Alerts. The manufacturer ceased production after yesterday’s raid. Below is a partial listing of the recalled items.


Alert—Sterility of all Products from Franck’s Compounding Lab
May 4, 2012

An outbreak of fungal endophthalmitis, first identified in California, has raised concerns about the sterility of products from Franck’s Compounding Lab: a Florida compounding pharmacy. This cluster of cases was in patients who had undergone vitrectomy with epiretinal membrane peeling using a dye called Brilliant Blue-G (BBG). All lots of BBG produced by Franck’s have been recalled.


Alert Supplement—Franck’s Compounding Lab recalls sterile drugs
May 24, 2012

Franck’s Compounding Lab today issued a recall of all sterile human and veterinary compounded prescriptions dated November 21, 2011, and later. The notice states that “it is essential that you do not use them and that employing appropriate practices, you destroy all such sterile preparations and all remaining portions of such sterile preparations.” This recall resulted from the FDA’s discovery of microorganisms and fungal growth in Franck’s clean room.The recall notice is posted at


Alert—KimVent® Closed Suction System (Adults) T-Piece
February 28, 2012

The cap needs to be removed for safe use in patients receiving continuous flow therapy.

CHPSO periodically reviews California Department of Public Health (CDPH) citations for opportunities to improve patient safety and prevent future events.In reviewing the following event, CHPSO identified a recurrent issue (as evidenced by reports in the FDA device event database).

The case