Medication management in community care: using hierarchical task analysis to describe complex systems

This paper presents an investigation into medication management at a UK Community Healthcare Trust. Data were collected at two community in-patient facilities to review practice at the two sites against the Standard Operating Procedures for (1) Medicines Management and (2) Controlled Drugs Management for four key tasks: ordering, transportation, receipt and storage of medicines. The variances in practice were discussed with senior management with the recommendation to simplify the system with a single SOP and provision of in-house pharmacy services at both sites.