Table 2

An all user group combined root cause analysis of critical tasks with more than four use errors*

TaskRoot causeUser (n)
SASSNCN
Task 127: Miscellaneous errors arising during general surgical procedureHUD component required replacing211
Sudden loss of insufflation due to center staff accidentally turning gas off1
Task 158: Apply brake to cartUsers forgot to apply brake to cart121
User thought task was performed by another user2
Task 76/Q9-1: What should you be careful of when unbraking the BSU?Users failed to mention possibility of trapping thin cables when BSU skirt is raised2423
User cognizant of correct answer but failed to mention it in their answer211
Task 239/Q15: If the BSU is disconnected from the surgeon console while in surgical mode, what will happen to the instrument assigned to that arm?Users stated they did not learn about it during training31
User could not recall the correct answer but stated it was covered in training2
Task 196/Q16: What do these icons mean? (hand detect)Users either could not remember the icons being discussed in training or were not paying attention to the particular icons in question22
User confused icons between two operation modes1
Task 334: Maintain sterilityUser unknowingly touched robotic arm trying to squeeze between arms2
User did not take it as a real procedure and small OR size12
User became distracted during use of Versius12
  • *All root causes of error were resolved following system design updates or modifications to the training protocol.

  • AS, assistant surgeon; BSU, bedside unit; CN, circulating nurse; HUD, head-up display; OR, operation room; S, surgeon; SN, scrub nurse.