Refill protocols and procedures were highly variable across this study’s sample of 11 family medicine residency program practices in a five-state region (Washington, Wyoming, Alaska, Montana, and Idaho). Surprisingly, formal written refill protocols were uncommon, present in less than half of the practices. This study’s sample size was too small to test for relationships between practice characteristics and the presence of a formal refill protocol. However, these descriptive findings suggest that far more practices with formal refill protocols hand off refills among providers, compared with practices that do not have a formal protocol. Such variability suggests that residency programs may not be role modeling best practices for refill protocols and procedures for future family physicians.
Practices with formal protocols reviewed patient-level data before refilling medications more often than practices without protocols, suggesting that the presence of a formal protocol may encourage optimal refill procedures. More errors may be inevitable without these protocols.7
In fact, an Agency for Healthcare Research and Quality patient safety study conducted in 31 primary care offices identified the absence of procedures such as routine screening for contraindications and precautions to medications as a major safety gap in outpatient medication prescribing, with the multiplicity of prescribers, medications, and pharmacies increasing the chance for undiscovered errors.3
Prescription refill workflow might also influence potential medication errors. A refill initiated from a pharmacy or a patient may involve a phone call, a phone message, or a faxed document managed by nurses or other staff. These individuals often transcribe medication names and dosages into the patient record in preparation for the refill. Errors could be made during any of these steps. One study showed that medication refill error rates increased from 25% to 100% as the number of people handling the medication management transaction increased from one to four or more.8
On the other hand, theoretically, multiple personnel involved in the refill steps could provide checks and balances for errors or potential sources of errors. This represents an important area for future research.
Although clinical pharmacist involvement in prescription refill was common in this study’s residency practices, their roles in the practices’ refill processes varied. These variable roles for clinical pharmacists have been documented or researched in other studies. Ellitt et al documented that some clinical practices, including integrated health systems and community health centers, have clinical pharmacists who authorize refills as part of a formal refill protocol,9
similar to a few sites in this study. In another study, “pharmacy refill clinics” that were staffed by clinical pharmacists identified patients with dosing errors or missing lab monitoring and contacted physicians with serious problems; this system provided overall cost savings and reduction in physician workload, which in turn allowed for improved appointment access for acutely ill patients.10
However, not all community-based practices will include an integrated clinical pharmacist. A logical next step for researchers would be to examine actual medical errors and patient outcomes associated with different refill systems both with and without the availability of a clinical pharmacist.
In this study, few residency practices had an identified champion for medication safety or a curriculum on medication safety. There is evidence that inclusion of a pharmacotherapy curriculum in residency training can increase knowledge.11
Resources, such as a sample pharmacotherapy curriculum developed by the Society of Teachers of Family Medicine,12
exist for educating residents about medication safety. Residency practices in particular have an important opportunity to improve prescribing and refill practices among the next generation of family medicine providers by teaching and role modeling optimal refill protocols and procedure.
This study has several limitations. First, the data were collected through key informants who may not have been familiar with the details of their residency practices’ refill protocols and procedures, especially those components with nursing or pharmacist oversight. It is possible that their responses to the interview questions were influenced by their own experiences rather than only reflecting their practices’ protocols and procedures. Our survey methods sought to minimize a bias from individual informants’ experiences by encouraging them to confer with others in their practice prior to answering interview questions. Second, this study included 11 residency-based practices whose results may not be generalizable to other residencies or to private practices. However, given the frequency of medication errors, including prescribing errors, widely cited in the literature,13
we surmise that refill protocol or procedure variability is a common theme in practices of all types, but especially among residency programs, due to the different nursing, mid-level, and pharmacist staffing models in these practices and the part-time clinical presence of resident and faculty physicians.
This study demonstrates that even in residency practices, which model medical care for future physicians, there are no standardized procedures for refilling medications. This is a particular concern given medication-related issues such as the documented high rates of chronic non-cancer pain and prescription opioid abuse behaviors that primary care providers experience in their practices.14,15
Future research systematically quantifying drug-related problems associated with different prescription refill protocols and procedures is warranted, especially in the area of opioid prescription. Such future studies of the association between different types of refill procedures, medication errors, and therapeutic outcomes can help identify best practices for refill protocols and procedures.