Background: Although most outpatients are relatively healthy, many have chronic renal insufficiency, and high\noverride rates for suggestions on renal dosing have been observed. To better understand the override of renal\ndosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently\nprescribed contraindicated medications, to assess providers� responses to suggestions, and to examine the drugs\ninvolved and the reasons for overrides.\nMethods: We obtained data on renal alert overrides and the coded reasons for overrides cited by providers at the\ntime of prescription from outpatient clinics and ambulatory hospital-based practices at a large academic health care\ncenter over a period of 3 years, from January 2009 to December 2011. For detailed chart review, a group of 6\ntrained clinicians developed the appropriateness criteria with excellent inter-rater reliability (? = 0.93). We stratified\nproviders by override frequency and then drew samples from the high- and low-frequency groups. We measured\nthe rate of total overrides, rate of appropriate overrides, medications overridden, and the reason(s) for override.\nResults: A total of 4120 renal alerts were triggered by 584 prescribers in the study period, among which 78.2%\n(3,221) were overridden. Almost half of the alerts were triggered by 40 providers and one-third was triggered by\nhigh-frequency overriders. The appropriateness rates were fairly similar, at 28.4% and 31.6% for high- and lowfrequency\noverriders, respectively. Metformin, glyburide, hydrochlorothiazide, and nitrofurantoin were the most\ncommon drugs overridden. Physicians� appropriateness rates were higher than the rates for nurse practitioners\n(32.9% vs. 22.1%). Physicians with low frequency override rates had higher levels of appropriateness for metformin\nthan the high frequency overriders (P = 0.005).\nConclusion: A small number of providers accounted for a large fraction of overrides, as was the case with a small\nnumber of drugs. These data suggest that a focused intervention targeting primarily these providers and\nmedications has the potential to improve medication safety.
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