Prevention is key to all aspects of healthcare, including patient safety. Case study material on topics like safety issues related to intra-hospital transfers will reveal how miscommunication and process inconsistencies compromise patient safety, and how silos within hospitals exacerbate the challenges. Recurrences can be eliminated and improvements sustained when organizations utilize RCA beyond satisfying regulatory requirements. Proactive RCA helps providers to identify and prevent the 20% of events that result in 80% of the annual losses. A tool kit will provide practical materials for implementing RCA to proactively eliminate undesirable outcomes, as well as improve processes and reduce costs.