Her et al developed a flow diagram to determine if an override to an alert for a nonformulary medication was appropriate or not. This was an attempt to streamline the process and to make it more efficient for clinical practice. The authors are from multiple institutions in Boston, Brussels and England.
Inappropriate override:
(1) nonformulary medication contraindicated for patient
(2) nonformulary medication significantly associated with risk to the patient (allergy, drug interaction, worsening of disease state, etc)
(3) override reason blank or of marginal value for the evaluating appropriateness of the nonformulary medication (reasons not clearly documented)
(4) a suitable alternative available in the formulary AND documentation does not support why it was not used
Appropriate override:
(1) no suitable alternative in formulary
(2) nonformulary medication being used prior to admission (home medication, other)
(3) all alternative medication(s) on formulary is documented as inappropriate for the patient AND nonformulary medication is appropriate
where:
• Criteria for evaluating a drug may include previous history of therapeutic failure, previous history of therapeutic success, indications, contraindications, adverse effects, route of administration, and recommendation by a specialist.
• Cost was not listed but would seem to be a valid concern.
