Ordering off the menu: assessing compliance with a nonformulary medication policy

Use of nonformulary medications (NFMs) may create added costs and potential safety issues. Institutional policies can support compliance with formulary systems and address these issues. However, periodic review is needed to assess the effectiveness of NFM policies.

To evaluate NFM use at a large university medical center and assess for compliance with the established policy as well as for prescribing errors, procurement procedures, and delivery times.

All new medication orders entered as NFM in the computerized order entry system during a 6-week period were evaluated and followed until administration of the first NFM dose. Orders were categorized as NFMs, formulary medications (FMs), or the patient's own medications. Each order was evaluated to determine the prescriber, service and location of the patient, and any prescribing errors. Additional information, such as the indication, location where the medication was obtained, and the delivery time, was obtained through patient chart review and the pharmacist intervention database.

A total of 237 orders were entered as nonformulary; 72 (30%) were FMs and 165 (70%) were NFMs. Of the 165 NFM orders, 71 (43%) were orders for the patient's own medication. Of the remaining 94 NFMs, only 39% met the institution's established policy criteria. Overall, 28% of all orders entered as nonformulary had a prescribing error. Of these, 49% were incorrect dosages and 33% were misspelled orders. Seventy percent of NFMs were obtained from the institution's standard locations. The institution's nonformulary turnaround time was achieved with 96% of NFMs.

The majority of NFM orders did not meet the institution's established criteria and these orders frequently contained prescribing errors. Routine assessment of NFM use and policy compliance can present opportunities for improvement.