Factors Influencing Hospital Physicians’ Recognition of Prescribing Cascades: A Qualitative Interview Study

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.