Better Decisions. Better Health for Kids.

Catastrophic Disaster Stories: Tales of CDS Gone Wrong and Lessons Learned

Allison B McCoy 1, Swaminathan Kandaswamy, PhD 2, Juan D Chaparro 3, Sean Hernandez 4, Evan Orenstein 2 5


Scientific publishing suffers from a lack of published negative results. Researchers are often reluctant to share their failures, yet many important lessons can be gleaned from these defeats. In implementation science, these failures are even more relevant as translating theory into practice in complex sociotechnical systems can yield unexpected or even dangerous results. In this panel, we will describe some of our most inglorious misfires as case vignettes in clinical decision support (CDS) implementation to share hard-earned lessons organized into 8 sociotechnical dimensions. Attendees will learn about CDS malfunctions.


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  1. Vanderbilt University Medical Center, Nashville, TN
  2. Emory University, Atlanta, GA
  3. Nationwide Children’s Hospital, Columbus, OH
  4. Wake Forest Baptist Health, Winston Salem, NC
  5. Children’s Healthcare of Atlanta, Atlanta, GA