The Wrong Trousers: Misattributing medical device issues to the wrong part of the sociotechnical system
HCI does not have well developed theoretical underpinnings to capture how different parts of a sociotechnical system impact medical device design and use. We report an issue that was identified during an ethnographic study of infusion pump use on a haematology ward: the frequency of the alarms caused frustration to staff and patients. Staff understood this to be a device design problem outside their control - a manufacturing issue. It is actually configured this way by the hospital - a device management issue. This misattribution impacts corrective action, and the quality and safety of patient care. We highlight three theoretical areas that could provide leverage for understanding issues such as this.