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BACKGROUND Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines. OBJECTIVE To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts. DESIGN Retrospective review. SETTING Tertiary care hospital. PARTICIPANTS Inpatient healthcare providers. INTERVENTION Provider‐BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record. MEASUREMENTS Provider (free‐text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ2 analysis and kappa scoring. RESULTS Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to “symptomatic” anemia (11%–12%). Many providers transfused in anticipation of surgical or procedural intervention (10%–15%) or imminent hospital discharge (2%–5%). Resident physicians represented the majority (55%) of providers interacting with BPAs. CONCLUSION Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors. Journal of Hospital Medicine 2015;10:1–7. © 2014 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine

Display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings.

These findings underscore the importance of understanding the unique strains and mental health consequences of a premedical curriculum, especially for women and certain minority ethnic populations. A meaningful next step would be a larger study, conducted by several representative university campuses, to confirm these findings; a follow-up of these cohorts could track longitudinal progress. More research must be done to determine the etiology of these findings with the ultimate intention of identifying opportunities for prevention and early intervention, which may provide significant public health payoffs in the long run.