Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

Root cause analysis (RCA) is one tool commonly used to identify factors contributing to adverse events. Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring during urologic procedures. The most common causes of adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong site surgeries, and retained surgical items.