Barriers and Facilitators to Hospital Physicians’ Recognition of Prescribing Cascades: A Qualitative Interview Study

Abstract Background A prescribing cascade occurs when a new drug is prescribed to manage an adverse effect of another medication. Prescribing cascades are clinically important as they can result in potentially avoidable harm to patients. Older adults are particularly vulnerable to prescribing cascades due to multimorbidity and polypharmacy. This study aimed to utilise the Theoretical Domains Framework (TDF), a validated theory-informed framework to explore behavioural factors influencing hospital physicians’ recognition of prescribing cascades. Methods Between May and July 2024 fourteen semi-structured interviews were conducted with hospital physicians of all grades. Interviews were audio-recorded and transcribed verbatim. Transcripts underwent content analysis to identify themes and Theoretical Domains Framework (TDF) domains. Results Four key TDF domains were identified: (i) Environmental context and resources: time pressures, staffing shortages, difficulty accessing accurate medication lists, and insufficient information technology (IT) infrastructure are barriers to recognition; (ii) Knowledge: many physicians were unfamiliar with the term ‘prescribing cascade’, and those who could define it acknowledged knowing only a limited number of specific examples. Physicians reported minimal education and training at undergraduate and postgraduate level; (iii) Skills: physicians typically develop the skill to recognise prescribing cascades through experiential learning (particularly while working with geriatric medicine consultants); (iv) Social/professional role and identity: participants identified themselves (the prescriber) as being primarily responsible for prescribing cascade recognition. Pharmacists provide a crucial role through obtaining accurate medication lists, medication review, and ward round participation. Some interviewees expressed greater confidence in recognising prescribing cascades that occurred within their own specialty. Conclusion This study reveals significant gaps in hospital physicians’ knowledge and understanding of prescribing cascades. Potential initiatives to address this include targeted education, improved IT infrastructure, improved access to accurate up-to-date medication lists and a collaborative physician-pharmacist approach. These interventions would likely improve prescribing cascade recognition, particularly in older people with multimorbidity and polypharmacy.