Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.
Nunnally M, Bitan Y. Time to Get Off this Pig's Back? J Patient Saf. 2008;2(3). doi:10.1097/01.jps.0000233827.90690.97.
The authors analyzed secondary (piggyback) infusions at their institution to illustrate human factors vulnerabilities in the process that could contribute to medication delivery failures.