Objectives: Operating room-related pressure injuries (ORPI) are particularly challenging to examine for several reasons. Time in the OR is often a distinct event within the hospitalisation, and discovery of an ORPI may occur between several hours and up to 5 days postoperatively. The National Pressure Injury Advisory Panel (NPIAP) first developed a root cause analysis (RCA) toolkit in 2017 as a systematic strategy for investigating the root causes of facility-acquired pressure injury (PI). The purpose of this 2021 RCA toolkit update was to address an expanded investigation of medical device-related PIs (MDRPIs), both inside and outside the OR, as well as the specific PI prevention issues of the perioperative area. Methods: Clinicians have been using the 2017 toolkit as a basis for ongoing quality improvement tracking, since it provides more accurate information than data extractions from patient health records. A small working group consisting of NPIAP board and panel members developed investigative questions to identify the ORPI root causes and compliance with best practices for the entire perioperative experience. Results: Action items are linked to evidence-based recommendations from the NPIAP/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance 2019 International Guideline and the Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice. A multidisciplinary clinician guide was also developed to identify practice gaps and to compile the information into an action plan for staff education and/or process improvement. Conclusion: The updated NPIAP RCA toolkit provides mechanisms for investigating, compiling and trending data as a basis for data-driven quality improvement. Using the enhanced investigative tools, the root causes of both MDRPIs and ORPIs can be better understood to target efforts to reduce their occurrence.