- Thorough, objective investigation of medical adverse events rarely happens due to the com- plexity of the environment, litigation, risk, and socio-political implications. Special concerns can, and do, undermine investigation depth, breadth, and quality. Healthcare's distinct differ- ence from other high hazard sectors requires a unique approach to adverse event investiga- tion. We report on the initial results of a 15-month pilot program now underway to model a national healthcare investigation team. An example of adverse event investigation and orga- nizational response illustrates these issues.