In healthcare, Root Cause Analysis (RCA) is "a structured method used to analyze serious adverse events." (1) The purpose of a non-punitive RCA is to discover any underlying flaws in procedures that enhance the likelihood of an error. When performed properly, an RCA can uncover factors that contributed to an adverse event, allowing steps to be put in place to address contributing factors, improve patient safety, reduce future incidences, and reduce risk-related costs. In order to begin a complete Root Cause Analysis, it is critical to create a safe, fear-free environment for event reporting. When an event is reported, an RCA is initiated. Furthermore, the technique utilized to conduct the RCA is critical in understanding why an incident occurred and how to avoid it in the future. A RCA is used to discover failures in processes and systems that lead to an unfavorable event by methodically studying the causes and effects of the many components of a process. When done correctly, root cause analysis in healthcare can improve safety, prevent future events, and eventually reduce total risk cost. Three Questions You Must Answer While approaches vary, the RCA process seeks to answer three questions: What occurred? What caused that to happen? What can be done to prevent it from happening again?