Factors influencing hospital physicians’ recognition of prescribing cascades: a qualitative interview study

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Date
2025-07-04
Authors
Daunt, Ruth
Dalton, Kieran
Curtin, Denis
O’Mahony, Denis
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Volume Title
Publisher
Springer Nature
Published Version
10.1007/s40266-025-01222-4
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Abstract
Introduction: A prescribing cascade occurs when a medication is prescribed to manage a side effect of another medication. Prescribing cascades represent a key component of problematic prescribing and can result in harm to patients, especially older adults with multimorbidity and polypharmacy. Objective: The objective of this study was to explore factors influencing hospital physicians’ recognition of prescribing cascades using the Theoretical Domains Framework (TDF), a validated theory-based qualitative methodology. Methods: Semi-structured interviews were conducted in May-July 2024 with hospital physicians of all grades. Interviews were audio-recorded and transcribed verbatim. Transcripts underwent conventional and directed content analysis to identify themes and TDF domains. Results: From 14 interviews, four predominant TDF domains were identified: (i) environmental context and resources: busy work conditions, lack of up-to-date medication lists and limited information technology (IT) infrastructure hinder prescribing cascade recognition; (ii) knowledge: physicians demonstrated limited knowledge of the term ‘prescribing cascade’ and highlighted education and training deficiencies at undergraduate and postgraduate level; (iii) skills: recognition skills are often developed through experiential learning while working (especially with geriatric medicine consultants) and (iv) social/professional role and identity: physicians perceived themselves as primarily responsible for recognising prescribing cascades, while pharmacists enable their recognition through medication reconciliation, medication review and ward round participation. Conclusions: This study highlights significant gaps in the knowledge and understanding of prescribing cascades among hospital physicians, as well as potential targets for future intervention. Focused education, integrated IT solutions, and a collaborative physician–pharmacist approach would likely improve prescribing cascade recognition in at-risk older people with multimorbidity and polypharmacy.
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Keywords
Care systems and practices , Complement cascade , Diagnosis , Health care , Medical education , Practice and hospital management
Citation
Daunt, R., Dalton, K., Curtin, D. and O’Mahony, D. (2025) 'Factors influencing hospital physicians’ recognition of prescribing cascades: a qualitative interview study', Drugs & Aging. https://doi.org/10.1007/s40266-025-01222-4
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https://hdl.handle.net/10468/17751
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Pharmacy - Journal Articles
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© 2025, the Authors. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.