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Commentary
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.
July 14, 2010
Nunnally M, Bitan Y. J Patient Saf. 2008;2(3).
The authors analyzed secondary (piggyback) infusions at their institution to illustrate human factors vulnerabilities in the process that could contribute to medication delivery failures.
