Abstract
Systems analysis is an approach used in situations requiring high reliability. In the past, the investigation and prevention of clinical error focused on the actions of individuals. A systems analysis approach to medical errors can identify and correct multiple contributing factors resulting in safer patient care systems. Recent analysis of a clinical error that occurred in public health practice identified multiple factors contributing to its occurrence. The use of the systems analysis approach resulted in high staff satisfaction and creative suggestions for operating a safer clinic and providing better patient care.