Medication dosage errors cause too many adverse clinical events in both inpatient and outpatient settings. In this disguised and partially fictionalized teaching case a hospital administrator considers whether the skills she recently acquired in an MBA Accounting Information System class could be adapted for use in a quality improvement program related to medication errors. The case illustrates how the preparation of a system flowchart mapped to a control matrix – a technique that auditors commonly use to support analysis of the adequacy of controls over financial processes – can be adapted to support analysis of clinical process controls and controls over related information. The case offers an opportunity for students to discuss some of the benefits and limitations of this technique, and possible extensions of it to non-financial processes in health care and elsewhere.