Why Sorting Tech Mistakes Isn't Enough

Patient safety classification systems help hospitals keep track of mistakes and near misses. They put events into boxes so people can compare and learn. These systems are used for watching trends, teaching staff, doing research, and making rules.

But when the problem comes from health information technology, things get tricky. Tech-related incidents often grow from many moving parts that change over time. They are not single, isolated events that happen at one moment.

Four common problems show up when we try to box these tech issues. First, the interaction between people, tools, and workflow gets split apart. Second, we lose the sense of how things evolve over time. Third, we miss how big the problem is and how it spreads across different systems. Fourth, we tend to blame the user alone, calling it use error and ignoring other factors.

These shortcuts can lead to wrong lessons, poorly aimed fixes, and hard-to-compare data across hospitals. Still, we don't need to throw the classification away. We just need to see it as one piece of a bigger picture that looks at the whole sociotechnical context.