Applying hierarchical task analysis to medication administration errors

Appl Ergon. 2006 Sep;37(5):669-79. doi: 10.1016/j.apergo.2005.08.001. Epub 2005 Sep 22.


Medication use in hospitals is a complex process and is dependent on the successful interaction of health professionals functioning within different disciplines. Errors can occur at any one of the five main stages of prescribing, documenting, dispensing or preparation, administering and monitoring. The responsibility for the error is often placed on the nurse, as she or he is the last person in the drug administration chain whilst more pressing underlying causal factors remain unresolved. This paper demonstrates how hierarchical task analysis can be used to model drug administration and then uses the systematic human error reduction and prediction approach to predict which errors are likely to occur. The paper also puts forward design solutions to mitigate these errors.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Humans
  • Medication Errors / prevention & control*
  • Medication Systems, Hospital / organization & administration*
  • Medication Systems, Hospital / standards
  • State Medicine
  • Task Performance and Analysis*
  • United Kingdom