Workshop 2 – Recognising the prescribing cascade

Linked to EAHP Statements

Section 4 – Clinical Pharmacy Services: Statements 4.1, 4.2
Section 5 – Patient Safety and Quality Assurance: Statement 5.1

ACPE UAN: 0475-0000-22-022-L04-P. An application-based activity.

Abstract

Incremental prescribing, also known as a prescribing cascade, is the result of a prescriber misinterpreting an Adverse Drug Event (ADE) as a new medical condition. The physician being unaware that the patient’s new symptom is of iatrogenic origin prescribes additional medications to the patient. The resulting increase in the number of medications can cause even more side effects and trigger further propagation of the prescribing cascade.
Prescribing cascades can happen to any patient, but they are more likely to happen in geriatric patients due to the higher number of medications they are on and the associated comorbidities. The identification and interruption of the prescribing cascade is essential to ensure medication safety in older people.

Although prescribing cascades are usually considered problematic and should be prevented or terminated, in certain clinical situations, they are considered therapeutically appropriate. On the basis of best available evidence, the prescribing cascades can be considered appropriate and intentional when the therapeutic benefit of the drug, that caused the ADE, outweigh the risk for the patient of having a new medication initiated to counteract the ADE.

It is important for the hospital pharmacist to be able to recognize prescribing cascades and, if considered problematic, to advise the prescriber on medications changes needed to terminate and prevent future problematic incremental prescribing.

In this interactive workshop, through case studies, the HP will acquire the skills needed to identify prescribing cascades and the skills to manage such situations which could be either termination or acceptance of the prescribing cascade.

Learning objectives
After the workshop, participants should be able to:

• Recognize prescribing cascades and distinguish between problematic and therapeutically appropriate cascades.
• Assess how the prevention and termination of problematic prescribing cascades enhances patient safety, with particular focus on elderly patients.
• Evaluate how patients can benefit from the acceptance of appropriate prescribing cascades.

Educational need addressed
This workshop addresses the skills needed by hospital pharmacists to recognize and manage prescribing cascades.

Keywords: Adverse drug events, prescribing cascades, geriatrics.