A Naloxone Best Practice Advisory That Failed to Signal: A Real‑World Evaluation of an Emergency Department

Naloxone BPAs in this community ED did not function as meaningful clinical signals. Although most alerts were acknowledged, they did not influence the distribution of THN kits and added minimal predictive value. Naloxone distribution reflected clinical cues, particularly acuity and opioid-related risk indicators, rather than BPA prompts. Redesign is needed to improve the timing, targeting, and relevance of naloxone-related clinical decision support (CDS). Future harm-reduction strategies should prioritize workflow-integrated, actionable CDS rather than broad, interruptive alerts that blend into background noise.