2013 Volume 13 Issue 4 Pages 185-188
The analysis of incident reports of each hospital is the most suitable way to prevent medical errors. As a results of the incident reports analysis at our hospital in 2008, missed medicine was the most frequent error, in which pre-breakfast α-glucosidase inhibitor (α-GI) being the most commonly missed drug. One of the reasons considered was nurses' lack of knowledge concerning α-GI medication. Occurrence of missed α-GI just before breakfast was independent of the years of experience of nurses.
From April 2009, we took preventive measures against missed α-GI by giving information about α-GI to all nurses in our hospital.
As a result, numbers of the incident reports about α-GI were decrease by 90.7% in 2009, by 94.4% in 2010 compared with that of 2008.
It suggested that to prevent medical errors, analysis of incident reports at each hospital and to obtain appropriate cooperation from nurses are effective.
