Affiliation:
1. National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, MI, USA
Abstract
In many operations, surgical staplers are utilized to ligate and divide blood vessels and other structures. Because staplers are often used to divide major blood vessels, adverse events may be associated with high morbidity and mortality. Previous research has identified a number of distinct failure modes. In the present study, 13 cases involving surgical staplers were identified in the Veterans Health Administration’s adverse event database. Pulmonary operations represented the largest group, and outcomes were generally severe. A large number of the root causes involved environmental factors; user, equipment, and task factors were also identified. While surgical stapler use is generally safe, there are a number of steps that surgical teams could take to promote safe use and recovery from adverse events.