Every workday, in every healthcare Risk Management office, lessons learned following patient injury investigation are buried when the case files are closed. This presentation will provide an overview of the changing role of individual case investigation, from its origins at the inception of healthcare risk management to its current status: a potent and underused tool for enhancing patient safety. We will examine seven case study examples of Risk Management-driven patient safety initiatives, differentiate their process from the current national safety and quality initiatives, and develop a road map for Risk Managers to provide unique leadership in making healthcare safer.