Regulatory requirements › Formulary review
The Joint Commission requires the drugs available for dispensing to be reviewed at least annually on emerging safety and efficacy information, and prescribes no method for doing it. ASHP recommends breaking the review into a rotating class schedule. This is that schedule for an inpatient hospital, covering 114 drug classes across twenty blocks.
Every formulary differs, and that is expected. What a class review can answer, and a drug list cannot, is whether the lineup is coherent: a formulary carrying pitavastatin but not rosuvastatin, or four carbapenems, or both phenytoin and fosphenytoin, has decisions in it that nobody made on purpose. 59 coherence checks are flagged below.
The other half of the job is what moved. A drug list does not change; the guidelines under it do, which is what "emerging safety and efficacy information" means in the standard. 38 recent changes are recorded against the classes they affect, each dated by its source so a stale one is visible rather than quietly wrong.
Every coherence check is labelled with what it rests on. Guideline means the governing guideline says so. Converged practice means many institutions reached it independently, which is weaker than a rule and stronger than an opinion. Unvalidated means it is reasoning from class logic that has not been checked against real formularies, and should be read as a question to ask rather than an answer. Most checks here are still unvalidated, and saying so is more useful than implying otherwise.
Four sections, from the published class review methodology. Keeping the format identical across classes is what makes the year's reviews comparable and what lets someone other than the author complete one.
Every formulary agent in the class with strength, dosage form and any restriction, plus the non-formulary agents in the class that were requested during the period.
Doses or units dispensed and acquisition cost for the period, formulary and non-formulary, with the trend against the prior period. Non-formulary volume is the signal that the formulary no longer matches practice.
Formulary addition and deletion requests, new or revised guidelines, boxed warnings, recalls, shortages, ISMP alerts and any local medication events involving the class.
Additions, deletions, restrictions, therapeutic interchanges and order set changes, each with a named implementation owner and a date. A recommendation with no owner does not reach a patient.
One or two blocks a month covers the formulary within twelve months. Order is deliberate: the highest volume and fastest moving classes come first, so the year starts where the evidence changes most.
The largest class by volume in most hospitals, the one most affected by annual guideline movement, and the one where stewardship restriction and formulary structure interact.
Coherence checkunvalidatedCarrying neither nafcillin nor oxacillin is a real gap: methicillin-susceptible S. aureus bacteremia treated with vancomycin has worse outcomes, so the definitive agent has to be on the shelf.
Coherence checkunvalidatedCeftriaxone and cefepime are near universal. Carrying ceftazidime as well needs a stated antipseudomonal or stewardship reason now that cefepime covers most of the same ground.
Coherence checkunvalidatedCefiderocol is a last-line agent and its presence should be tied to a restriction policy and an ID approval pathway, not to open formulary status.
Coherence checkunvalidatedMeropenem plus ertapenem covers nearly all inpatient need. Carrying all four carbapenems is a common finding with no therapeutic rationale and a stewardship cost.
Coherence checkunvalidatedAlmost no hospital needs all four. Selection should follow the local antibiogram and the resistance mechanisms actually seen, and each should carry ID approval. This is the highest-cost decision in the block.
CoverageWhat the 2026 ESBL guidance changes at discharge How the 2025 pneumonia guidelines changed order sets
Coherence checkunvalidatedJustified mainly as the severe beta-lactam allergy option. If the hospital runs a penicillin allergy delabeling program, aztreonam use should be falling.
Coherence checkunvalidatedLong-acting lipoglycopeptides are usually a discharge-avoidance or IV-access decision rather than a clinical one. If one is on formulary, the review should show who approves it and whether it actually avoided admissions.
Coherence checkunvalidatedThree fluoroquinolones is rarely defensible after the tendon, aortic and neuropathy warnings. Most hospitals can justify two, and many restrict all three.
Coherence checkunvalidatedErythromycin often survives on formulary only for its prokinetic use. If so, the review should say that plainly so it is not mistaken for an anti-infective option.
Coherence checkunvalidatedTigecycline carries an all-cause mortality warning. Its continued presence should be tied to a specific indication rather than to habit.
Coherence checkunvalidatedCurrent guidance favours fidaxomicin over oral vancomycin for initial episodes. A formulary carrying only oral vancomycin should record why, since cost is a legitimate reason but should be a stated one.
Coherence checkunvalidatedVoriconazole and posaconazole both require therapeutic drug monitoring. If neither has a monitoring protocol, the formulary is carrying risk it is not managing.
Coherence checkunvalidatedOne echinocandin covers nearly all inpatient need. Carrying two or three is usually contract history rather than a clinical decision.
Coherence checkunvalidatedConventional amphotericin persists on many formularies purely on cost. If it is stocked, there should be an explicit statement of when it may be used, because the nephrotoxicity difference is not subtle.
Coherence checkunvalidatedInpatient HIV continuation is the main driver. The real question is whether the formulary can continue a patient's home regimen without interruption, which is a medication reconciliation problem as much as a formulary one.
Coherence checkunvalidatedMost hospitals carry two DOACs and continue the others from home supply. The review should confirm the renal dose adjustment logic in the EHR matches each agent, since this is a frequent source of error.
Coherence checkunvalidatedCarrying prasugrel without a stated cath lab protocol is a common finding. Its contraindication in prior stroke or TIA makes an unrestricted listing a safety issue.
Coherence checkunvalidatedMany stroke programs have moved to tenecteplase. If both are stocked, the review should confirm which is the default in each protocol, because carrying two thrombolytics with unclear roles is a look-alike risk.
CoverageWhy the stroke guideline change is really about systems
Coherence checkunvalidatedIf a DOAC is on formulary, the review should state what reverses it and where that agent is stocked. A formulary with apixaban and no documented reversal pathway is the gap most likely to be found during an event review rather than a survey. With andexanet alfa off the US market, four-factor PCC is the practical factor Xa pathway for most hospitals, and that decision should be written into the reversal policy with a dose rather than left implied.
CoverageWhy the disappearance of andexanet is a documentation problem
Why the class carries what it carriesNot a count. Published formulary decision processes converged on an intravenous agent plus one oral agent from each duration tier, short-acting, intermediate and long-acting. Captopril is the short-acting tier and earns its place for titration in unstable patients, which is why it survives on formularies that otherwise standardise hard. Beyond one agent per tier, additional oral ACE inhibitors are usually home-therapy continuations and are better handled by therapeutic interchange than by stocking, which is what roughly nine in ten hospitals do.
Coherence checkconverged practiceAsk which tier each agent occupies rather than how many there are. A formulary with four long-acting agents and no short-acting one has a real gap despite looking well stocked. Cost also runs opposite to intuition here. Lisinopril is usually the cheapest and oral enalapril is not, so a cost argument for consolidation has to be checked against actual acquisition price rather than assumed.
Why the class carries what it carriesUnlike the ACE inhibitors, the ARBs do not separate cleanly by duration tier and no intravenous agent exists, so the tier argument does not apply. What drives the count is intolerance handling and home-therapy continuation. Valsartan carries the heart failure and post-infarction evidence and candesartan the heart failure evidence, so an agent kept for those indications is a stated reason rather than duplication.
Coherence checkconverged practiceTwo agents plus a documented therapeutic interchange covers most institutions. Before deleting, check which agents your prescribers actually continue from home, because an interchange nobody follows generates non-formulary requests instead of savings.
CoverageThe 2025 hypertension guideline and the new calculator
Coherence checkunvalidatedHeart failure benefit is established for carvedilol, metoprolol succinate and bisoprolol. If the formulary carries metoprolol tartrate only, the review should address the substitution risk at discharge.
Coherence checkunvalidatedNicardipine and clevidipine overlap almost entirely. Carrying both needs a stated reason, usually volume restriction in the neuro or cardiac population.
Coherence checkunvalidatedNow guideline-directed therapy for heart failure regardless of diabetes status. A formulary that still lists these only under diabetes is out of date.
CoverageWhy a crashing eGFR might be good news Why heart failure therapy got a radical remake
Coherence checkunvalidatedMethyldopa is largely an obstetric agent now. If the hospital has no obstetric service, its presence is worth questioning.
Coherence checkunvalidatedDofetilide and sotalol require inpatient initiation with QT monitoring. If either is on formulary, the review should confirm the monitoring protocol exists.
Coherence checkunvalidatedDopamine has largely been displaced by norepinephrine. Continued stocking should be tied to a specific use rather than to inertia.
Coherence checkunvalidatedThe formulary has to support all three intensity tiers, which in practice means atorvastatin and rosuvastatin at high intensity. Pravastatin earns its place on drug interactions, for the transplant and HIV populations. Pitavastatin is the classic incoherence: it offers little the others do not, at substantially higher cost, and a formulary carrying it without rosuvastatin has no defensible rationale.
CoverageWhy the 2026 lipid guidelines change the target Beyond the max statin: the 2025 ACS guideline
Coherence checkunvalidatedRarely initiated inpatient. The real question is whether the formulary can continue a patient already on one, and whether the discharge pathway is defined.
Coherence checkunvalidatedGemfibrozil with a statin is a known myopathy interaction. If both are on formulary, an interaction alert should exist.
Coherence checkunvalidatedOne rapid analogue is enough. Carrying aspart and lispro and glulisine at once is a look-alike risk with no therapeutic benefit, and it is one of the more common findings in this class.
Coherence checkunvalidatedU-500 is a recurring source of tenfold errors. If it is stocked, the review should confirm the storage separation, the dedicated syringe and the independent double check are in place.
Coherence checkunvalidatedMost agents in this group are held inpatient. The review should state which are continued, which are held, and whether the EHR reflects that, since the answer drives a large share of medication reconciliation work.
CoverageWhat the ADA changed for hospitalised diabetes technology Rethinking the eGFR dip on SGLT2 inhibitors
Coherence checkunvalidatedPTU is preferred in the first trimester and in thyroid storm. If the hospital has an obstetric or ICU service, its absence is a gap rather than a saving.
Coherence checkunvalidatedAllopurinol is first line including in chronic kidney disease, which is the opposite of long-standing practice. A formulary that restricts allopurinol by renal function, or positions febuxostat as the renal alternative, is working from superseded guidance and carrying the febuxostat cardiovascular warning for no reason.
Coherence checkunvalidatedLocal vaginal estrogen and systemic hormone therapy are not the same risk profile and should not share a warning or a restriction. A formulary treating them identically is carrying a labeling error that the FDA itself has now corrected.
Coherence checkunvalidatedMorphine and hydromorphone confusion is one of the most frequently reported error pairs. The review should confirm concentration standardisation and storage separation rather than assuming it.
Coherence checkunvalidatedCodeine and tramadol both depend on CYP2D6 and carry pediatric contraindications. Carrying both alongside oxycodone rarely adds anything.
Coherence checkunvalidatedIV acetaminophen is a cost outlier. The review should show the criteria that restrict it to patients who genuinely cannot take oral, or it becomes a budget line nobody owns.
Coherence checkunvalidatedNaloxone availability at discharge is a stewardship expectation now. If the formulary carries no take-home naloxone pathway, that is a finding waiting to happen.
Coherence checkunvalidatedThree parenteral benzodiazepines with different potencies and durations is a concentration and look-alike risk. The review should confirm which is the default for each indication: status epilepticus, procedural sedation, alcohol withdrawal and palliative use are four different answers, and leaving them unstated is how substitution errors happen. Flumazenil is not a routine reversal agent and its availability should not imply otherwise, since it can precipitate seizures in the benzodiazepine-dependent patient.
Coherence checkunvalidatedParalytics are the highest-consequence look-alike risk in the hospital. The review should confirm segregated storage, auxiliary labeling and removal from any unit that cannot ventilate, and vecuronium's continued presence alongside rocuronium should be justified rather than assumed.
Coherence checkunvalidatedThe safety question in this class is not agent selection, it is whether lipid emulsion rescue is stocked and reachable wherever these are used in volume, including areas outside the operating room such as emergency, endoscopy and labour and delivery. A formulary carrying bupivacaine in a procedural area with no rescue pathway is the gap. Liposomal bupivacaine costs many multiples of the standard product and needs a stated indication rather than open availability.
Coherence checkunvalidatedCarrying both phenytoin and fosphenytoin invites a dosing error, since one is expressed in phenytoin equivalents and the other is not. Most hospitals should carry one, and the review should say which and why.
Coherence checkunvalidatedMissed levodopa doses cause real harm within hours. A formulary with only oral forms and no transdermal or enteral pathway should note how an NPO patient is managed.
Coherence checkunvalidatedClozapine requires REMS enrollment and absolute neutrophil count monitoring. If it is on formulary, the review should confirm the monitoring and dispensing pathway exists, because carrying it without one is worse than not carrying it.
Coherence checkunvalidatedThe class carries a real continuation risk: abrupt discontinuation on admission causes withdrawal. The review should confirm the formulary can continue common home agents or has a documented substitution table.
Coherence checkunvalidatedOne IV proton pump inhibitor and one oral is enough. Multiple oral PPIs on formulary is a frequent finding and a straightforward deletion.
Not a class so much as an indication, and the evidence has moved. The review should check that prophylaxis criteria exist and that patients are not discharged on a PPI started only for prophylaxis.
Coherence checkunvalidatedPromethazine carries a boxed warning for severe tissue injury. If it is stocked, the review should confirm the administration standard, dilution and route restriction.
Coherence checkunvalidatedInhalers are where formulary and home therapy diverge most. If the hospital cannot continue a patient's device, the review should document the substitution table and whether the patient is taught the new device before discharge.
Coherence checkunvalidatedConcentrated potassium chloride is the original never-event medication. The review should confirm it is not stocked in patient care areas outside defined exceptions, and that premixed bags are the default.
Coherence checkunvalidatedThe balanced crystalloid question now has enough evidence to deserve a stated institutional default rather than prescriber preference. Carrying both saline and a balanced solution with no guidance on which is first line means the choice is made by whatever is stocked closest. Hydroxyethyl starch has largely been abandoned on renal and mortality grounds; its continued presence needs a specific reason.
CoverageThe 89% bet: your ICU's default fluid and the one exception
Coherence checkunvalidatedSodium polystyrene sulfonate carries a bowel necrosis concern. If newer binders are on formulary, the review should say when the older agent is still appropriate.
Coherence checkunvalidatedFactor products are among the highest cost line items in the pharmacy. Each should carry an approval pathway and a documented indication set, or the spend is uncontrolled by design.
Coherence checkunvalidatedBiosimilar conversion in this class is one of the clearest savings available. If the formulary still lists only the originator, the review should record why.
See the anticoagulation block; reversal agents are reviewed with the agents they reverse.
Coherence checkunvalidatedTacrolimus formulations are not interchangeable and the error is a serious one. If transplant patients are admitted at all, the review should confirm the EHR distinguishes immediate from extended release.
Coherence checkunvalidatedBiosimilar availability changes this class every year. A class review that does not check biosimilar status is leaving the largest available saving untouched.
Coherence checkunvalidatedRabies prophylaxis is low volume and high urgency. If it is not stocked, the review should document where it is obtained and how quickly, because discovering that during an exposure is too late.
Coherence checkunvalidatedStocking decisions here should follow a written antidote stocking assessment based on the hospital's actual exposure risk, not on a generic list. The failure mode is discovering an antidote is not stocked while a patient is decompensating.
Educational reference for licensed pharmacists. Not a formulary recommendation for any institution and not clinical advice. Agent groupings reflect common acute-care practice, not a standard of care. Verify every guideline against its current version, and make formulary decisions through your own P&T process.