The investigation of human error analysis in adverse drug events in Taiwan—From the perspective of causality assessment

The goal of this study is to analyze the adverse drug events, using the human factors analysis and classification system (HFACS), and to identify the causality between the error factors. Twenty‐five cases related to medication errors were identified. Seven experts were recruited to form an expert team for this study. The HFACS and root cause analysis were utilized in this study to identify the causal factors and the root causes of medication errors. The frequency of each error factor was recorded, and odds ratio was applied to measure the strength of the relevance of the error factors between adjacent levels of the HFACS. The results showed that 222 errors were identified and the main pathways and subpathways of medication errors from Level 4 to Level 1 of the HFACS were arranged in this study. According to the results, the deficiencies in organizations could be the main reasons causing adverse drug events in Taiwan.