The Fragility of Critical Medication Alerts in Electronic Prescriptions: The Need for Governance and Organizational Culture

Abstract

This opinion article discusses the limits and fragility of automated prescription alerts for critical medications when implemented in healthcare systems without proper clinical governance and cultural alignment of the teams. Although Clinical Decision Support Systems (CDSS) are designated as essential barriers to error prevention, excessive and miscalibrated signaling triggers the phenomenon of alert fatigue, leading professionals to compulsively dismiss warnings and become desensitized to risk. Additionally, it examines how the high cost of acquiring and maintaining these technologies, when isolated from improvements in care processes, pressures public and private budgets without generating effective safety gains. It is concluded that technology is not self-sufficient and that the effectiveness of alerts depends on the consolidation of the triad between people, processes, and technology, supported by standardized clinical protocols and ongoing continuing education programs.