Application of root cause analysis (RCA) continues to serve an important role in improving patient safety and quality, with past studies describing RCA use in Veterans Affairs facilities and tertiary referral hospitals. This commentary discusses the history and experience of RCA and points out the lack of evidence supporting its use to reduce risk or improve safety. Also absent are best practices for establishing recommendations for action, follow-up, and analyzing results. The authors suggest that many recommendations stemming from RCAs should focus at the level of the health care system to prevent the inefficiencies of having individual institutions recycle the same discussions locally. This would require greater collaboration among relevant national stakeholders to develop and share mechanisms for deploying scarce implementation resources. A past AHRQ WebM&M commentary discusses the steps in conducting an RCA.