Why digital health fails silently: a sociotechnical theory of health information technology-related risk.

Introduction: Health information technology (HIT) is now integral to healthcare delivery, supporting clinical documentation, prescribing, diagnostics, and care coordination. Although these technologies offer substantial benefits, they have also introduced new patient safety risks that are often difficult to anticipate, detect, or manage. Many HIT-related safety problems arise not from isolated technical failures or individual mistakes, but from complex interactions between digital systems, clinical work practices, organisational structures, and governance arrangements. Traditional patient safety models that focus on discrete errors or linear causality are therefore insufficient for explaining how digital risks emerge and persist in practice. Methods/theoretical approach: This article develops a sociotechnical theory of HIT-related risk grounded in patient safety science and sociotechnical systems theory. The theory is informed by empirical insights from incident-based research on HIT-related safety problems and synthesises evidence from real-world incident narratives. It adopts a conceptual, theory-building approach informed by purposive, iterative engagement with the relevant literature on health IT safety, sociotechnical systems, and resilience-oriented patient safety frameworks. Rather than analysing a single dataset, the paper identifies recurring mechanisms through which digital risks arise, remain hidden, propagate across contexts, and become recoverable or not. Results/theoretical propositions: The proposed theory conceptualises HIT-related risk as a dynamic process involving four interrelated mechanisms: risk emergence, risk concealment, risk propagation, and recoverability. Risks emerge through misalignments between system design, configuration, and clinical workflows; they are concealed by automation, information fragmentation, and adaptive workarounds; they propagate through tightly coupled digital infrastructures and shared dependencies; and their recoverability depends on organisational capacity for detection, escalation, and learning. Together, these mechanisms explain why HIT-related incidents may affect multiple patients or services, why attribution to individual error is misleading, and why safety problems may persist despite corrective efforts. Discussion/implications: By reframing HIT-related incidents as manifestations of system-level vulnerabilities rather than isolated failures, this sociotechnical theory provides a coherent explanatory framework for understanding digital patient safety. It highlights how risks can evolve silently within routine practice, vary in visibility and scale, and emphasises the importance of organisational learning, governance, and resilience in managing digital safety risks.