First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.