233 Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to errors. A network of hospitals and outpatient centers recognized an opportunity to enhance and standardize our approach to root cause analyses (RCAs). As leaders, we have an imperative to prevent issues that can result in a safety event; yet we have an even greater moral obligation to correct causes once an event occurs to prevent it from happening again. Methods: A framework was established to prevent recurrence through a focus upon root solutions. Recognizing that human error is not the cause of the failure but a symptom, the goal is to understand why it made sense for individuals to do what they did by reconstructing the world in which they found themselves at the time of the event. The includes: 1) training staff on high reliability; 2) assigning an executive to remove barriers; 3) creating a charter; 4) conducting 1:1 interviews; 5) deploying tools (such as sequence of event diagramming, validation and verification of raw data, human error type classification; individual/system failure and event/causal factor charting); 6) transporting findings; and 7) action planning with controls. A 3-meeting model was embraced. Results: As of April 2019, 9 events have been investigated. Event types include: infusion hours/splitting orders, incorrect lab order, retained object, wrong patient medication administration, patient brachytherapy underdosing, wrong site delayed treatment, rapid response call delay, and delay in care for extravasation. The 12-month rolling average serious safety event rate per 10,000 patient days decreased from 1.93 to 1.33 since implementation. With 6 months experience under the enhanced framework, plans also exist to monitor events from similar root causes as a success measure. Summaries allowing this level of analyses include event description, immediate actions, proximate versus root causes, and corrective actions. Conclusions: The capacity to learn from experience is essential to patient safety. Adherence to the framework ensures movement beyond proximate to root causes. It is a means to spread knowledge using proven tools based upon principles of high reliability.