This study discusses the practical use of health care failure mode and effects analysis (HFMEA) by presenting a real case example of this qualitative methodology. Discussion focuses on creating an initial process flow diagram and how information obtained through interviews adds necessary detail to those flow charts. The mapped-out process then leads to identification of potential failures and the development of strategies to address them. The authors conclude that HFMEA may allow systems to uncover latent errors beyond those discovered with root cause analyses or quantitative techniques.