[To err is human but error can be prevented]

It is believed that behind each reported medical error 29 unreported errors are hidden and in addition 300 irregularities are present. To prevent medical errors, one should learn from those latent errors to reorganize or correct systems and procedures. The Risk Management Committee is in charge of taking measures to prevent errors based on the analyzed data reported by risk managers and/or on incident/accident reports. The incident/accident reports should be made under a blame-free system and the concept should be thoroughly understood by all hospital staff. A lack of mutual communication, lack of a system to prevent medical errors, and lack of seriousness in everyday practice among physicians and nurses were found to be underlying causal factors in medical errors based on the lessons learned in our institution.