Based on findings of the Utilization/Peer Review Forum, a quality assurance system committee comprising public health professionals, there was a question about whether public health nurses followed the standards of care when treating children with anemia. The article describes the process of identifying the problem and then developing and implementing an investigation to determine the magnitude of the problem. A sample of 703 child care records was audited. As a result of this process, conflicts in the established protocols of the county health department were identified, and an unexpectedly high prevalence of childhood anemia was discovered.