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Journal Article > Study
Dominguez ED, Rocos B. Cureus. 2019;11:e4877.
This analysis of the National Reporting and Learning Service database (the United Kingdom's voluntary error reporting system) identified numerous cases of patient harm due to malfunctioning surgical equipment, the most common involving unretrieved device fragments (such as broken drill bits). The authors contend that lack of a standardized reporting and tracking system for surgical instrument malfunctioning poses a potential threat to patients. A WebM&M commentary discussed an incident involving life-threatening hemorrhage due to a broken surgical instrument.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Journal Article > Commentary
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.