Patient safety incident investigations offer unique opportunities to encourage continuous learning and system improvements. Researchers in this study analyzed 126 action plans generated from serious event investigations at one hospital in the United Kingdom to assess how well the proposed patient safety actions generated from incident investigations aligned with contributing factors identified in the investigations. The analysis found that 15% of contributory factors were not addressed by the action plans and that three-quarters of proposed risk controls outlined in the plans were weak (focusing on individual rather than systemic issues).