Dear Editor
The excellent analysis of prescribing cascades in this edition of the BMJ [1] illuminates the seemingly intractable adverse drug reaction problem [2]. The avoidable harm due to incomplete monitoring of repeated prescriptions has been documented for decades [3], despite the World Health Organisation (WHO) global challenge [2]. The full extent of avoidable harm is uncertain, but known associations require close monitoring, as some adverse effects are irreversible. Up to 20.37% (95% CI 16.89, 23.85) of primary care patients experience adverse drug reactions [4].
As indicated in the insightful commentary [5], the professional gaze should now focus on interventions to mitigate the impact of adverse drug reactions and associated prescribing cascades. Pharmacist reviews improve prescribing, but a review encompassing ~400,000 patient records found almost no effect on patient outcomes [6]. As Linsky and Boockvar say, potential problems need to be distinguished from actual problems [5]. Medicines chart reviews identify potential problems, but not actual problems. Real-time signs and symptoms can only be recognised by patient contact. If patients or carers note problems on a structured pro forma, this can be reviewed by nurses, pharmacists and/ or prescribers, then juxtaposed with medicines charts, with or without decision support. This way, prescribers are alerted if patients prescribed laxatives have diarrhoea, or elderly patients prescribed zopiclone and promethazine are falling, act accordingly, and improve care [7]. Randomised controlled trials indicate that this intervention (the ADRe Profile) reduces problems, such as pain, and averts serious events, such as B12 deficiency in patients prescribed metformin or falls in patients with dementia prescribed risperidone [8,9]. Patients welcome the intervention, describing it as “a good thing - should be put in place for people, everybody” (service user 2, care home 1) [7] and “a 3-cornered arrangement which works” (patient 21) [9]. However, clinicians indicate that patient-centred monitoring takes time and confronts them with more problems than they have capacity to manage [9].
The GMC (2024) Item 101 states: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient [10]. How this should be done, and by whom, is unspecified: few patient-centred monitoring tools have been tested in randomised controlled trials. Ideally, patients would be checked for all ‘undesirable effects’ listed in the summaries of product characteristics issued by manufacturers. However, if patients are taking several medicines, this is likely to be impractical, and interventions such as the ADRe Profile offer an evidence-based compromise. Currently, patient-centred monitoring for the adverse effects of prescribed medicines is a task orphaned by divisions between primary and secondary care, and interprofessional boundaries between medicine, pharmacy, and nursing. Work outside the remit of established professional groups or unoccupied professional territory may attract emerging professional groups, such as pharmacy technicians, who are likely to play important roles in future medicines reviews. Interventions with decision support, such as the ADRe Profile, may prove useful.
1. Rochon P A, Austin P C, Gurwitz J H, Wu W, Matai L, Zhang T et al. Exploring high priority potentially inappropriate prescribing cascades in older adults: population level retrospective cohort study BMJ 2026; 394 :e100499 doi:10.1136/bmj-2026-100499
2. World Health Organisation. Medication without harm: policy brief. Geneva: World Health Organisation; 2023. Available from: https://iris.who.int/server/api/core/bitstreams/1eacccb6-838e-4787-bfd9-... (accessed 24th April 2026)
3. Gandhi TK, Weingart SN, Borus J, Seger AC, Seger DL, Peterson J, et al. Adverse Drug Events in Ambulatory Care. NEJM. 2003;348(16):1556–64. DOI: 10.1007/s40264-024-01501-w
4. Insani WN, Whittlesea C, Alwafi H, Man KKC, Chapman S, Wei L. Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis. PLOS One. 2021;16(5). DOI: 10.1371/journal.pone.0252161
5. Linsky A M, Boockvar K S. Assessing inappropriate prescribing cascades BMJ 2026; 395 :e100801 doi:10.1136/bmj-2026-100801
6. Persaud N, Workentin A, Rizvi A, Pierson T, Bortolussi-Courval É, Liu K, Bennett A, Shaver N, Skidmore B, Vyas N, Pap R, Almoli F, Lee TC, Sirois C, McCracken RK, Papillon-Ferland L, McDonald EG. (2025) Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2;8(6):e2517965. doi: 10.1001/jamanetworkopen.2025.17965. PMID: 40577011; PMCID: PMC12205406.
7. Jordan S, Prout H, Carter N, Dicomidis J, Hayes J, Round J, Carson-Stevens A. (2021) Nobody ever questions—Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative. PLOS ONE 16(1): e0244519. https://doi.org/10.1371/journal.pone.0244519
8. Jordan S, Gabe-Walters ME, Watkins A, Humphreys I, Newson L, Snelgrove S, et al. Nurse-Led Medicines’ Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial. PLOS One. 2015;10(10). DOI: 10.1371/journal.pone.0140203
9. Logan V, Conboy A, Carter N, Hughes D, Turner A, Watkins A, Jordan S. "A better system" - managing the adverse effects of prescribed medicines: Cluster-randomised controlled trial and process evaluation of the ADRe Profile in primary care. PLoS One. 2026 Sep 18;21(9):e0356480. doi: 10.1371/journal.pone.0356480. PMID: 42758689.
10. GMC 2021, updated 2024 Professional standards In effect: 5 April 2021 GMC, London https://www.gmc-uk.org/-/media/documents/prescribing-guidance-updated-en... Items 100 & 101 https://www.gmc-uk.org/professional-standards/the-professional-standards...
No AI was used in the preparation of this letter.
We have no financial interests in deployment of any interventions. The ADRe Profile is free to use.
The Adverse Drug Reaction Problem: from epidemiology to intervention