Elder abuse and neglect are serious yet preventable problems in the United States. Approximately five million Americans are estimated to be victims of elder abuse and neglect each year, and just one in 24 cases are reported to authorities. Stacy A. Drake, co-director of the Harris County (Texas) elder fatality review team, named EFFORT, discusses how she and other team members identify cases of possible abuse or neglect in this article from the National Institute of Justice’s “Notes from the Field” series. To identify an opportunity for system-level improvement, each case undergoes a deep dive review by the EFFORT members looking at the circumstances of death. Stacy A. Drake, Ph.D., MPH, RN, AFN-BC, D-ABMDI, FAAN, is an associate professor at Texas A & M University’s College of Nursing. Her research is focused on establishing and working within an interdisciplinary team to address gaps within the delivery of healthcare systems via understanding the social determinants of health anchored among populations who die sudden unexpected deaths for prevention purposes.