title: The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.
abstract: Experts suggest that formulary alerts at the time of medication order entry are the most effective form of clinical decision support to automate formulary management.
  
  
  
  Our objectives were to quantify the frequency of inappropriate nonformulary medication (NFM) alert overrides in the inpatient setting and provide insight on how the design of formulary alerts could be improved.
  
  
  
  Alert overrides of the top 11 (n = 206) most-utilized and highest-costing NFMs, from January 1 to December 31, 2012, were randomly selected for appropriateness evaluation. Using an empirically developed appropriateness algorithm, appropriateness of NFM alert overrides was assessed by 2 pharmacists via chart review. Appropriateness agreement of overrides was assessed with a Cohen's kappa. We also assessed which types of NFMs were most likely to be inappropriately overridden, the override reasons that were disproportionately provided in the inappropriate overrides, and the specific reasons the overrides were considered inappropriate.
  
  
  
  Approximately 17.2% (n = 35.4/206) of NFM alerts were inappropriately overridden. Non-oral NFM alerts were more likely to be inappropriately overridden compared to orals. Alerts overridden with "blank" reasons were more likely to be inappropriate. The failure to first try a formulary alternative was the most common reason for alerts being overridden inappropriately.
  
  
  
  Approximately 1 in 5 NFM alert overrides are overridden inappropriately. Future research should evaluate the impact of mandating a valid override reason and adding a list of formulary alternatives to each NFM alert; we speculate these NFM alert features may decrease the frequency of inappropriate overrides.
authors.affiliation: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, One Brigham Circle, Harvard Medical School, Boston, MA 02120, USA qher@partners.org.
authors.forename: Qoua L
authors.initials: QL
authors.lastname: Her
authors.affiliation: Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
authors.forename: Mary G
authors.initials: MG
authors.lastname: Amato
authors.affiliation: Clinical and Quality Analysis, Information Systems, Partners HealthCare System, Inc., Wellesley, MA, USA.
authors.forename: Diane L
authors.initials: DL
authors.lastname: Seger
authors.affiliation: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, One Brigham Circle, Harvard Medical School, Boston, MA 02120, USA Research Center for Medical Informatics, University Hospital Zurich and University of Zurich, Switzerland.
authors.forename: Patrick E
authors.initials: PE
authors.lastname: Beeler
authors.affiliation: Wolfson Research Institute, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Stockton-on-Tees, TS17 6BH, UK.
authors.forename: Sarah P
authors.initials: SP
authors.lastname: Slight
authors.affiliation: Louvain Drug Research Institute, Clinical Pharmacy Research Group, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Avenue Mounier 73, B-1200 Brussels, Belgium.
authors.forename: Olivia
authors.initials: O
authors.lastname: Dalleur
authors.affiliation: Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Dykes
authors.affiliation: Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: James F
authors.initials: JF
authors.lastname: Gilmore
authors.affiliation: Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: John
authors.initials: J
authors.lastname: Fanikos
authors.affiliation: Clinical and Quality Analysis, Information Systems, Partners HealthCare System, Inc., Wellesley, MA, USA.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Fiskio
authors.affiliation: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, One Brigham Circle, Harvard Medical School, Boston, MA 02120, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D000046:Academic Medical Centers; D000465:Algorithms; D001900:Boston; D020000:Decision Support Systems, Clinical; D004360:Drug Therapy, Computer-Assisted; D005572:Formularies, Hospital as Topic; D006760:Hospitalization; D006801:Humans; D050316:Medical Order Entry Systems
keywords: alerts; appropriateness; clinical decision support; computerized provider order entry; hospital formulary