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

OBJECTIVES: Automated piggybacks are purported to make drug administration safer and more reliable. We evaluated the human factors of piggyback infusion, investigated the practice in our institution, and analyzed incidents from an anonymous database to better characterize the practice and substantiate these assertions. METHODS: To find examples of problems with piggyback, or secondary infusions, we searched the Food and Drug Administration's on-line incident database for incidents involving piggybacks. As part of a task analysis, 19 senior nurses each programmed 2 of 4 different pumps for a simulated piggyback infusion. To characterize infusion practice, we evaluated data logs from 55 infusion devices used in our institution. RESULTS: Incidents from the database provided strong evidence that potential problems existed with piggyback infusions. Nurse behaviors suggested mismatches between the task, user, and devices that can lead to adverse events. Log files showed piggybacks were a common practice, and that available safeguards were not used. CONCLUSIONS: Our multiple data sources suggest automated piggyback infusion practice is neither simple nor safe. Incident report analysis suggests these findings contribute to adverse events. Further study is needed to understand and improve the safety of this practice.