Can a new pharmacy tool catch prescribing cascades before they cause harm?

A new pharmacist-led screening tool shows promise for identifying potential prescribing cascades among long-term care residents, although researchers found that medication-order data alone often lacked the clinical context needed to determine whether a true cascade had occurred.Published in the Canadian Pharmacists Journal, the quality improvement initiative evaluated Cascade-Watch, an electronic screening report that uses routinely available medication-order data to identify potential prescribing cascades.A prescribing cascade occurs when an adverse drug event is mistaken for a new medical condition, prompting the addition of another medication rather than addressing the underlying drug-related cause.The initiative was conducted across three long-term care facilities in Vancouver, B.C. Cascade-Watch was designed to operationalize ThinkCascades, a framework identifying nine clinically important prescribing cascades. The tool flagged specified drug pairs initiated within 180 days of one another.During the first Plan-Do-Study-Act cycle, Cascade-Watch flagged 248 potential prescribing cascades among 138 residents. The most frequently flagged medication pairs were antidepressant-sedative combinations (48), benzodiazepine-related cascades (35) and antipsychotic-associated cascades (28).After reviewing the cases using available chart information and clinical judgment, pharmacists classified 246 of the 248 flagged medication pairs as indiscernible from true prescribing cascades. Incomplete symptom timelines and unclear reasons for starting medications made it difficult to distinguish potential cascades from appropriate prescribing or progression of an underlying disease. Only two medication pairs were assessed as true prescribing cascades.Pharmacists were also hesitant to recommend medication changes without sufficient diagnostic clarity. Actions were conservative and included temporary medication holds, dose reductions and recommendations for reassessment rather than immediate discontinuation.The authors concluded that the first cycle demonstrated the feasibility of using medication-order sequencing to flag potential prescribing cascades in long-term care, but the tool had limited initial impact on reducing them. Future refinements are expected to incorporate more clinical context, improved cascade classification, targeted education and enhanced decision support.“This is a true blend of informatics and pharmacy collaboration,” said lead study author and pharmacist Adam Bleik.

Can a new pharmacy tool catch prescribing cascades before they cause harm?

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