Clinical decision support systems show mixed real-world effectiveness in reducing preventable adverse drug eventsAI tools show mixed results in preventing drug errors

Preventable adverse drug events (ADEs) remain a major source of hospital morbidity, mortality, and healthcare costs worldwide. Clinical decision support systems (CDSS) integrated into electronic health records (EHRs) were developed to reduce unsafe prescribing, yet evidence of their real-world effectiveness remains mixed. The emergence of artificial intelligence (AI) and machine learning (ML) offers new opportunities to enhance medication safety but also introduces risks such as algorithmic bias, technology-induced error, and reduced clinician vigilance. This narrative review critically examines: (1) evidence for the effectiveness of CDSS in reducing preventable ADEs; (2) human factors influencing interactions between clinicians and AI-enabled safety tools; and (3) conceptual, methodological, and governance challenges affecting the safe implementation of digital health technologies. A structured narrative review was conducted using the SANRA framework and reported in accordance with PRISMA-ScR guidance where applicable. Searches of PubMed/MEDLINE, CINAHL, Embase, Scopus, and IEEE Xplore covered literature published between January 2015 and March 2024, supplemented by seminal earlier studies. Following eligibility screening, 75 studies were included in a thematic synthesis and quality appraisal using established risk-of-bias tools. Five themes emerged: the transition from passive to adaptive decision support; AI's dual role as both a safety enhancer and a source of new risks; persistent alert fatigue; the often-overlooked contribution of nursing vigilance; and gaps in equity, governance, and technology-induced error research. From these findings, we propose the Clinical Safety Intelligence Loop (CSIL), a conceptual framework that positions AI within a sociotechnical system while embedding equity, governance, and continuous feedback as core components. Achieving medication safety improvements requires moving beyond technology-focused solutions toward systems-level approaches integrating AI, clinician cognition, organizational culture, and governance. The CSIL offers a useful framework for guiding this transformation, although further empirical validation is needed.