| Sumario: | The article focuses on the challenges and opportunities in designing digital adverse drug event (ADE) management systems within healthcare. It highlights that while digital tools have the potential to improve medication safety, many existing systems suffer from poor integration with clinical workflows and broader healthcare infrastructures, limiting their effectiveness and sustainability. The authors argue for a systems-thinking approach that goes beyond user-centered design to address system-wide alignment, including financial, regulatory, and policy factors, to ensure long-term adoption and impact. Key concepts introduced include "Therapeutic Misalignment," where digital solutions do not fit healthcare contexts, and "Formulation Instability," referring to the failure of solutions to sustain over time without proper governance and funding. The article calls for structured implementation strategies and multi-stakeholder engagement to develop scalable, integrated digital health innovations that enhance patient safety and clinical decision-making.
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