Context:Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health Research (NCRHR) to overcome these barriers in 6 Nebraska critical access hospitals (CAHs). Participating Nebraska CAHs mailed copies of medication error reports to the NCRHR monthly for entry into a database. Quarterly summaries enabled each CAH to compare its reports by severity, type, phase of the medication use process, contributing factors, and causes to those of its peers and MEDMARX, a national medication error reporting program. Workshops emphasized learning from the reported errors by identifying system sources of variation in medication use and initiating change to achieve best practices. Similar to MEDMARX, 99% of medication errors reported by 6 Nebraska CAHs were not harmful, reported errors most often originated in the administration phase, and the most common error type was omission. The CAHs reported significantly smaller proportions of "near miss" errors and errors originating inthe prescribing phase than in MEDMARX. By collaborating with CAHs, an academic medical center, and a national reporting program, the NCRHR is translating the Institute of Medicine's recommendation for voluntary error reporting into practices that allow CAHs to learn about and improve their medication use systems. However, limited presence of pharmacists in CAHs is a barrier to implementing double checks and learning from system failures in the medication use system.