Table 4. Themes and illustrative quotes from study participants about opportunities for improvement in alerts.

Themes	Quotes
Alert timing and design	“I think I preferred for it [alert] to pop up when I was entering the medications, because then I did not get too far in the ordering process…” ( Intern 1 ) “I liked the first method where it [alert] pops up right away because… especially if it's a matter of just having a dose or something like that. It'd be nice to know that going into writing the order sentence so that you can make that adjustment… Otherwise you have to cancel and rewrite the whole thing. See, I definitely like the order earlier.” ( Resident 2 ) “…if I put everything else and it wasn't until I went to sign that it [alert] popped up, I feel like appropriately or inappropriately my only option would be to cancel everything I had done and start over, which would drive me nuts” ( Attending 2 ) “I don't know if there would be a way to kind of make more of a table or kind of delineate those two things [two interacting drugs].So what's the interaction, why, alternative medications that are recommended, and just for easy visual understanding” ( Attending 2 ) “I think a better idea is to make the alerts more well designed so that they're more informative, they're quicker, and in particular they're more unambiguous to deal with… Don't give people six or seven different choices for things, just choose two or three that really reflect what people are thinking.” ( Cardiologist 3 ) “I think it did require me to read it carefully because at first it said, well, the fact that the alert box popped up is unusual enough that it makes me want to read it. But you do have to go through a few lines to get to the point.” ( Attending 3 ) “I think it's [alert box] a little too dense honestly. It's almost like I wish the two bullet… main bullet points were separated so it was a little bit easier to read because I… I'm trying to get as much information as I can quickly to be list should I order this or should I not. And I find it a little dense to read. I'm not going to lie.” ( Attending 4 )
Unmet informational needs	“It would have been helpful if there was an explanation of what the risk is… SSRIs are contraindicated with this type of thing because if the risk of serotonin syndrome or kidney failure, and then I could sort of know what I was thinking or maybe that would trigger something.” ( Attending 1 ) “If there'd been a prior EKG available, [that] would be useful.” ( Attending 2 ) “I think if there was a quick click that I could review that [recent EKG or QTc], yeah, that would be helpful.” ( Cardiologist 1 ) “…with the methadone I feel like, well, usually we would say prescribe it anyway, just check an EKG ” (Attending 2) “…if that [alert window] would actually give me the nature of the interaction, because, you know… if it was like a minor interaction, that I'd want to be aware of but wouldn't necessarily, you know, make me say, ‘Oh. I’m not going to order this until I get more information'” ( Neurologist 3 ). “want to know more about why he [patient] was on the valproic acid” and was planning “to see if they got levels before he was admitted” ( Cardiologist 2 )
Additional sources of information
Pharmacists as source of information	“I'd want to call pharmacy first and say I'm getting this alert, does… should I do that... this for this child in this setting, and then I would probably do tha t ” ( Resident 2 ) “It's telling me to consider modification of my order by decreasing the dose of lamotrigine. So I'm going to speak with pharmacy with regard to this interaction before putting in the order” ( Cardiologist 1 ) “…in our program we are told to be very comfortable with reaching out to pharmacy whenever we have a question …and it's something you can do while you're doing other things” ( Resident 2 ) “My base is always just to call pharmacy because I find that it's a lot easier for me to just talk it through with somebody that knows what they're doing.” ( Attending 2 ) “As a resident, I would probably discuss this with attending, the fellow, and then also maybe just talk with pharmacy about how much of a risk …” ( Resident 1 ) “So I probably would not order this for her [patient] and talk more with Sr. Resident.” ( Intern ) “So I'm adding these medications, none of which I am familiar with at all...I mean, honestly, before I'm probably doing any of this, I am going to Lexicomp, double-checking… Again, there's no dose-checking, it seems here [alert window], so if I hadn't double-checked specific doses before, I would definitely go to Lexicomp and double-check” ( Attending 3 ) “I think if it's a straightforward dosing question, or if it's a, could this be a side effect question, I will use Lexicomp. Like if it's just going to be a quick answer that I think I can get easily” ( Attending 3 ) “I would go ahead and place the orders, but I would talk to either the coagulation or the cardiology service about how much of a risk that is…” ( Resident 1 ) “…So talking with the neurologist to help make a good decision in that case” ( Cardiologist 4 ) “I think from the work flow standpoint it's much more efficient for people to click on a Lexicomp or UpToDate as long as you trust that resource. For major decisions I think I probably would still refer to a pharmacist.” ( Cardiologist 1 ) “From the work flow standpoint, it's much more efficient for people to click on a Lexicomp or UpToDate” ( Cardiologist 1 ) “And I actually might go back to the mom and verify that he's taking both of these medications ” ( Attending 4 ) “…if it's something that I have comfort with, so say a rash to a cephalosporin or more commonly what we see is a rash to amoxicillin when I'm trying to write a cephalosporin that I feel fairly confident with and can… have usually had the conversation with the family ahead of time and found out what that rash is, is it one of these vague potential non allergies or is it Stevens-Johnsons. And so if it's a big potential non allergy that's very mild that I've already discussed with the family, I would go ahead and kind of override it. If not or if I'm not sure, again, I would probably kind of go back to the family and find out what the allergy was and how concerned I need to be ” ( Attending 2 ) “So I'd go ask the parent, how much is he actually getting?” In a follow-up to the same scenario, the neurologist added “I usually trust what the parents are saying unless there is some reason not to” ( Neurology 3 )

Abbreviations: EKG, electrocardiogram; SSRI, selective serotonin reuptake inhibitor.