A lost surgical specimen prompted an investigation of both the human processes and the systemic factors involved in surgical specimen handling regarding how health care organizations approach medical error prevention and patient safety promotion. Quality improvement techniques and the conceptual error model of James Reasons were employed to understand the interaction between the local process of specimen handling and the systemic influences to medical error management. Error management recognizes the inevitability of both individual and systemic error. Through the use of quality improvement techniques and models of error analysis, health care organizations can investigate the error potential of health care delivery and address the human and organizational interaction necessary to improve patient safety and manage medical error.