Table 2.
An all user group combined root cause analysis of critical tasks with more than four use errors*
| Task | Root cause | User (n) | |||
| S | AS | SN | CN | ||
| Task 127: Miscellaneous errors arising during general surgical procedure | HUD component required replacing | 2 | 1 | 1 | – |
| Sudden loss of insufflation due to center staff accidentally turning gas off | – | 1 | – | – | |
| Task 158: Apply brake to cart | Users forgot to apply brake to cart | – | 1 | 2 | 1 |
| User thought task was performed by another user | – | – | 2 | – | |
| 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 raised | 2 | 4 | 2 | 3 |
| User cognizant of correct answer but failed to mention it in their answer | – | 2 | 1 | 1 | |
| 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 training | 3 | 1 | – | – |
| User could not recall the correct answer but stated it was covered in training | – | – | – | 2 | |
| 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 question | – | 2 | – | 2 |
| User confused icons between two operation modes | 1 | – | – | – | |
| Task 334: Maintain sterility | User unknowingly touched robotic arm trying to squeeze between arms | – | 2 | – | – |
| User did not take it as a real procedure and small OR size | – | 1 | 2 | – | |
| User became distracted during use of Versius | 1 | – | 2 | – | |
*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.