1. Leape, LL, "Error in Medicine," JAMA 272 (1994): 1851-1857. 2. Leape, LL, DW Bates, DJ Cullen, et al, "Systems Analysis of Adverse Drug Events," JAMA 274 (1995): 35-43. 3. Mongeau, C, "Voices From Colorado," Nursing98 (June 1998). 4. Reason, J, Human Error. Cambridge, Mass: Cambridge University Press; 1990. 5. Smetzer, JL, "Beyond Blaming Individuals: Lesson From Colorado," Nursing98 (May 1998).