In October 1996, a medication error at a Denver-area hospital resulted in the death of a newborn infant. The error involved the intravenous administration of a large dose of penicillin G benzathine, which is only to be given intramuscularly. The three nurses involved in the error were indicted for criminally negligent homicide, and blame for the death focused on them individually. In analyzing the error, the authors (experts from the Institute for Safe Medication Practices) discovered more than 50 latent system failures that contributed to the death. The authors discuss the need to look beyond individuals and focus on the multiple system failures that often result in medication errors.