Attitudes, behaviors, and relationships in health care influence the safety of patient care. This study aimed to identify systemic and relational human factors that contribute to serious adverse events. Root cause analysis investigation reports from two hospital districts were analyzed. Overarching themes included delays and inertia, with a subtheme of inertia of ageism; “all-or-nothing” approach to end-of-life care and planning; communication lapses; and implementation gap between standards and practice.