This study examines the utility of root cause analysis (RCA) to identify, investigate, and address reported adverse drug events (ADEs). Discussion includes a description of the RCA system employed, examples of events analyzed, and an informative table sharing systematic changes resulting from the analyses. Although the intervention produced several opportunities for improvement, the emphasis also required a blame-free atmosphere and institutional support. The authors conclude that systematic application of root cause analysis, coupled with implementation of process changes, can serve as a powerful mechanism for institutional improvement.