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VHA National Center for Patient Safety

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Hazard Summaries

Hazard summaries were developed to share information about safety risks involving specific patient care issues. The summaries identify hazards and provide guidance on how to mitigate the associated risks.

Anticoagulation Vulnerability

The medication use process is one of the most complicated processes in health care, with anticoagulant use being among the most difficult of all therapies to manage. If patients have risk factors for bleeding, they may be predisposed to bleeding if the protocols are not sufficiently adjusted to accommodate for the increased risk of bleeding. Read more about anticoagulation vulnerability.


Portable Blood Glucose Monitors (BGMs), also known as Glucometers, are portable, battery operated medical devices that measure the blood glucose concentration from a small drop of capillary blood (from finger sticks or alternate sites) using methodologies such as: reflectance photometry, absorbance photometry, or electrochemistry. Read more about glucometers.

Magnetic Resonance (MR)

This hazard summary provides highlights and generalities and deals primarily with issues pertaining to use of medical devices in the MR environment. Read more about magnetic resonance.

Oxygen (Compressed Gas) Cylinders

This summary addresses portable medical grade oxygen cylinders (also called tanks or bottles). This summary is a SUPPLEMENT; it DOES NOT replace existing guidelines and directives for proper handling, storage, and operation of medical oxygen (e.g., Joint Commission guidance on storage of "E" cylinders). Read more about compressed gas cylinders.