RCA is an assessment that provides details after the event has occurred and outlines the series of steps taken that led to the event and identifies factors associated with the challenge event. RCA is used to describe; “trends and risk assessment that can be used whenever human error is suspected” (Hughes, 2008). It is believed that once the root of the problem is determined it is easier to repair it. Another system they can use to evaluate the system is failure modes and effects analysis (FMEA). The FMEA method is more of an evaluation method or technique that will eliminate known and possible system faults, problems, concerns, and errors before they actually occur. This method is known for prevention by predicting errors by estimating probability and penalties. Achieving strategic improvement requires strong leadership, a good source of financial resources for training purposes, and the necessary equipment to empower healthcare workers. Educate stakeholders on how this will benefit the entire organization and lead to fewer adverse events within the system. They will have to come together to develop a more precise solution to the problems and address them through interdisciplinary communications and cooperation that can jeopardize the safety of healthcare culture. To move forward everyone must feel part of the change and feel that their concerns have been addressed. Patients and their families must be assured that every effort is made to correct any areas of concern. Root cause analysis must be made aware of its use and importance in the process. Behind all the efforts