Human factors methods to reduce medication error: using task analysis in a pediatric and adult pharmacy Nicole E. Werner, * Erik T. Nelson, a and Deborah A. Boehm-Davis a a Psychology Department, George Mason University, 4400 University Drive, MS3F5, Fairfax, VA 22030, United States. Abstract. Medication error is an issue that no hospital is immune from, leading to 7,000 deaths and 1.3 million patient injuries each year. The purpose of this study was to decrease the risk and occurrence of medication errors by analyzing the hospital pharmacy. Task analyses were performed and it was found that communication, expectation, and procedural issues were lead- ing to the occurrence of the most common type of medication error in the pharmacy. Recommendations were made to improve the process and reduce the occurrence of this type of error. Keywords: Patient safety, medication error, task analysis, pharmacy * Nicole E. Werner. E-mail: nwerner2@masonlive.gmu.edu 1. Introduction According to the 1999 Institute of Medicine report, “To err is human,” human error in medicine leads to the deaths of up to 98,000 people per year [3]. Medi- cation errors are defined as an error that occurs dur- ing any part of the medication dispensing process. This process starts with the provider who writes the prescription, goes through the pharmacy who tran- scribes and dispenses the prescription, and ends with the nurses who administer the prescription. Medication error is an issue that no hospital sys- tem is immune from. In fact, medication errors have been reported to contribute to 7,000 deaths and 1.3 million patient injuries each year [1]. In addition to harm to patients, medication error also leads to an enormous expense for the healthcare system. In 2000, $177.4 billion was spent for injuries caused by medi- cation errors [2]. Because of the high cost to patient’s well being, as well as monetary cost to the healthcare system, it is important to develop and apply new ways of reducing medication errors. This study set out to identify potential causes of medication errors for patients served by an adult and pediatric satellite pharmacy within a large suburban hospital system. Human factors and task analysis techniques were used to identify these errors. 2. Practice Innovation Observations of pharmacy staff initially began with 30 minute to two hour sessions followed by un- structured interviews regarding processes and culture. Later, unstructured interviews were conducted with the nursing staff on the several floors/wings of the hospital with regard to their perceptions of the medi- cation preparation process, as well as the transfer of medications from the pharmacy to the nursing floor. From these information gathering techniques, two task analyses were conducted; a Barrier Analysis and an Operational Sequence Diagram. Work 41 (2012) 5665-5667 DOI: 10.3233/WOR-2012-0913-5665 IOS Press 5665 1051-9815/12/$27.50 © 2012 – IOS Press and the authors. All rights reserved