title: Lesson from Colorado. Beyond blaming individuals.
abstract: A medication error that killed a newborn and resulted in criminal charges against three Denver nurses didn't have to happen. Use this step-by-step account of what went wrong to discover system flaws that may threaten your patients.
authors.affiliation: Institute for Safe Medication Practice, Warminster, Pa., USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Smetzer
mesh_terms: D003120:Colorado; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008508:Medication Errors / Q000331:legislation & jurisprudence*; D009741:Nursing Staff, Hospital / Q000193:education / Q000331:legislation & jurisprudence*; D012308:Risk Management / Q000379:methods*; D012449:Safety