Medication errors: analysis not blame.

This article summarizes current knowledge regarding neonatal medication errors and explicates the key concepts of human error and system error. A case report illustrates the sources of error. Medication error analysis must go beyond the blaming of individuals for active errors and explore the latent errors that exist in a complex health care environment. Using correct language to describe and define medication error may facilitate the development of a nonpunitive culture and enable effective evaluation of the causes of error.