. 2025 Oct;16(5):1573-1584.

doi: 10.1007/s41999-025-01215-x. Epub 2025 Jul 31.

International expert panel's potentially inappropriate prescribing cascades (PIPC) list

Paula A Rochon^{1

2

3

4

5}, Denis O'Mahony^{6

7}, Antonio Cherubini^{8

9}, Graziano Onder^{10

11}, Mirko Petrovic¹², Kieran Dalton¹³, Lisa M McCarthy^{14

15

16}, Shelley A Sternberg¹⁷, Donna R Zwas¹⁸, Nathan M Stall^{19

20

21}, Christina E Reppas-Rindlisbacher^{19

20}, Nathalie van der Velde^{22

23}, Sarah N Hilmer^{24

25}, Wei Wu¹⁹, Joyce Li¹⁹, Amy Ly¹⁹, Jerry H Gurwitz²⁶

Affiliations

¹ Women's Age Lab and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. paula.rochon@wchospital.ca.
² ICES, Toronto, ON, Canada. paula.rochon@wchospital.ca.
³ Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁴ Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁵ Sinai Health System, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁶ Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland.
⁷ Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
⁸ Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy.
⁹ Geriatria, Accettazione geriatrica e Centro di Ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy.
¹⁰ Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy.
¹¹ Center of Aging, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy.
¹² Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium.
¹³ Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
¹⁴ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
¹⁵ Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
¹⁶ Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
¹⁷ Department of Medicine, Division of Geriatrics, Maccabi Healthcare Services, Tel Aviv, Israel.
¹⁸ Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
¹⁹ Women's Age Lab and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
²⁰ Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
²¹ Sinai Health System, Toronto, ON, Canada.
²² Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
²³ Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
²⁴ Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, Australia.
²⁵ Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
²⁶ Division of Geriatric Medicine, UMass Chan Medical School, Worcester, MA, USA.

PMID: 40742670
PMCID: PMC12712104
DOI: 10.1007/s41999-025-01215-x

International expert panel's potentially inappropriate prescribing cascades (PIPC) list

Paula A Rochon et al. Eur Geriatr Med. 2025 Oct.

. 2025 Oct;16(5):1573-1584.

doi: 10.1007/s41999-025-01215-x. Epub 2025 Jul 31.

Authors

Affiliations

¹ Women's Age Lab and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. paula.rochon@wchospital.ca.
² ICES, Toronto, ON, Canada. paula.rochon@wchospital.ca.
³ Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁴ Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁵ Sinai Health System, Toronto, ON, Canada. paula.rochon@wchospital.ca.
⁶ Department of Medicine (Geriatrics), School of Medicine, University College Cork, Cork, Ireland.
⁷ Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork, Ireland.
⁸ Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy.
⁹ Geriatria, Accettazione geriatrica e Centro di Ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy.
¹⁰ Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy.
¹¹ Center of Aging, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy.
¹² Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium.
¹³ Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
¹⁴ Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
¹⁵ Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada.
¹⁶ Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
¹⁷ Department of Medicine, Division of Geriatrics, Maccabi Healthcare Services, Tel Aviv, Israel.
¹⁸ Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
¹⁹ Women's Age Lab and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
²⁰ Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
²¹ Sinai Health System, Toronto, ON, Canada.
²² Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
²³ Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
²⁴ Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, Australia.
²⁵ Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
²⁶ Division of Geriatric Medicine, UMass Chan Medical School, Worcester, MA, USA.

PMID: 40742670
PMCID: PMC12712104
DOI: 10.1007/s41999-025-01215-x

Erratum in

Correction: International expert panel's potentially inappropriate prescribing cascades (PIPC) list.
Rochon PA, O'Mahony D, Cherubini A, Onder G, Petrovic M, Dalton K, McCarthy LM, Sternberg SA, Zwas DR, Stall NM, Reppas-Rindlisbacher CE, van der Velde N, Hilmer SN, Wu W, Li J, Ly A, Gurwitz JH. Rochon PA, et al. Eur Geriatr Med. 2026 Feb;17(1):409-410. doi: 10.1007/s41999-025-01378-7. Eur Geriatr Med. 2026. PMID: 41410825 Free PMC article. No abstract available.

Abstract

Purpose: Prescribing cascades contribute to potentially inappropriate prescribing, especially among older adults. With the prescribing cascade framework maturation, it is important to distinguish potentially inappropriate from potentially appropriate prescribing cascades. The objective was to create a comprehensive consensus list of Potentially Inappropriate Prescribing Cascades (PIPCs).

Methods: A prescribing cascade inventory was compiled using published lists. An international panel of 12 experts in geriatric medicine and pharmacology was selected. Panelists participated in a Delphi consensus process completing two questionnaire rounds and one discussion round.

Results: A total of 107 proposed prescribing cascades were identified. After Questionnaire Round 1, 56 prescribing cascades achieved a rating of agree or strongly agree by ≥ 75% of the panelists and were included in the PIPC list. For 32 of the 107 proposed cascades, 50-74% of panelists provided a rating of agree or strongly agree, and were moved to Round 2. In Questionnaire Round 2, 9 of 32 proposed cascades achieved a rating of agree or strongly agree by ≥ 75% of panelists and were included in the final PIPC list. For 14 prescribing cascades, 50-74% of panelists provided a rating of agree or strongly agree, and were included in the Discussion Round. After discussion, no additional prescribing cascades were included.

Conclusion: An explicit list of 65 PIPCs was created using a rigorous Delphi consensus process conducted by international experts on pharmacotherapy for older adults. The PIPC list provides a crucial tool for clinicians and researchers to detect potentially inappropriate prescribing patterns and to foster efforts to improve medication safety.

Keywords: Delphi consensus; Older adults; Optimizing drug therapy; Prescribing cascade.

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Conflict of interest statement

Declarations. Conflict of interest: The authors have no competing interest that are directly or indirectly relevant to the content of this study. Ethical approval: The study was approved by the Research Ethics Board of Women’s College Hospital (REB #: 2024-0011-E). Informed consent: The protocol was registered in Open Science Framework ( https://doi.org/10.17605/OSF.IO/7DF62 ).

Figures

**Fig. 1**
Potentially appropriate and potentially inappropriate prescribing cascade

**Fig. 2**
Compiling an inventory of prescribing cascades for evaluation. Legend: The Figure describes the steps followed to compile the inventory of prescribing potentially inappropriate cascades for evaluation

**Fig. 3**
Delphi process to seek consensus on an extensive list of Potentially Inappropriate Prescribing Cascades (PIPC). Legend: The Figure describes the three phases followed to create the consensus list of 65 Potentially Inappropriate Prescribing Cascades (PIPCs)

See this image and copyright information in PMC

References

1. World Health Organization (2017) Medication Without Harm - Global Patient Safety Challenge on Medication Safety. 2017. Licence: CC BY-NC-SA 3.0 IGO. Accessed May 26 2020. . https://www.who.int/patientsafety/medication-safety/medication-without-h...
1. Duerden M, Avery T, Payne R (2013) Polypharmacy and medicines optimization—Making it safe and sound. The King's Fund (https://assets.kingsfund.org.uk/f/256914/x/0ffd18f8d6/polypharmacy_medic...), accessed on 9 Jan 2025).
1. Rochon PA, Gurwitz JH (1997) Optimising drug treatment for elderly people: the prescribing cascade. Rev BMJ (Clin Res ed) 315(7115):1096–1099 - DOI
1. McCarthy LM, Savage R, Dalton K et al (2022) ThinkCascades: a tool for identifying clinically important prescribing cascades affecting older people. Drugs Aging 39(10):829–840. 10.1007/s40266-022-00964-9 - DOI - PMC - PubMed
1. Deprescribing Guidelines and Algorithms - Deprescribing.org. Deprescribing.org. Accessed 21 Nov 2024. https://deprescribing.org/resources/deprescribing-guidelines-algorithms/

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International expert panel's potentially inappropriate prescribing cascades (PIPC) list

Affiliations

International expert panel's potentially inappropriate prescribing cascades (PIPC) list

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

Figures

References

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources