成熟した組織の臨床意思決定支援プロセスを改善するためのアラート誤動作の10日間を活用したCDS障害に関する特集号

Interruptive clinical decision support (CDS) alerts are intended to standardize patient care and prevent harm. However, failures can occur even in organizations with mature CDS governance and advanced analytics. These breakdowns, marked by excessive firings, workflow disruption, and clinician dissatisfaction, can provide insights into systemic weaknesses in CDS design, testing, and monitoring processes.

To examine a CDS alert malfunction as a lens for identifying system-level gaps and propose strategies to strengthen resilience in CDS operations.

A retrospective analysis was conducted on an interruptive alert that was developed through a phased, multi-stakeholder, committee-driven process but removed within ten days due to poor performance, revealing gaps that persisted despite established governance.

The alert fired 1,866 times in five days, with a 91% dismissal rate and reports of workflow disruption. Feedback indicated provider frustration and concern for malfunction. Analysis revealed gaps in end-user engagement, testing rigor, committee reviews, and monitoring practices.

CDS failures can serve as catalysts for system improvement. This case highlights actionable lessons, such as operationalizing user-centered design, clarifying testing expectations, and distributing monitoring responsibilities, to enhance CDS reliability. Even well-established governance structures must be continuously evaluated and adapted to keep pace with evolving CDS technologies, and such investments position organizations to maintain responsive, sustainable systems aligned with high-quality care.