Recurring concern
Failure to identify clinically significant medication risks
- Reports that mention this concern
- 54
- Times this concern has been raised
- 58
- Stated actions linked to this concern
- 100
What this concern includes
Includes failures in medication review, reconciliation, prescribing or screening that concern recognising the clinical significance of a medicine, contraindication, interaction, toxicity, side-effect or existing medication.
What is not included
- Excludes failures to administer, monitor or supply medication where the concern is not specifically the identification of medication-related risk.
- Excludes illicit or general drug-use hazards not tied to a medication-safety control.
- Excludes generic failures to recognise symptoms or deterioration unless the report explicitly links them to medication-related risk.
- Excludes generic communication, documentation or staffing deficiencies that are not dedicated to identifying medication risks.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 54 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of standardised guidance for asking questions about possible medication side effects
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Herefordshire and Worcestershire Health and Care NHS Trust
Use the Clozapine Clinic standard operating procedure and GASS to monitor and record clozapine side effects in electronic patient records.
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Herefordshire and Worcestershire Health and Care NHS Trust
Re-issue the Clozapine Treatment Guidelines and clinic guidance to the mental health clinical workforce.
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Herefordshire and Worcestershire Health and Care NHS Trust
Undertake follow-up to ensure newly appointed and existing staff are aware of and comply with both clozapine guidance documents.
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Concerns raised1
Limited awareness of the significance of salbutamol overuse in patients and families
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to provide specific advice to stop Candesartan and identify its pregnancy risk
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Riverview Surgery
- Royal College of General Practitioners
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Riverview Surgery
Implement and apply an SOP covering pregnancy-related safety checks for new medicines, including stopping or replacing medicines unsafe in pregnancy.
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Riverview Surgery
Use reception tasks to trigger pregnancy coding, midwife referral checks and medication reviews, with duty-GP cover when unavailable.
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Riverview Surgery
Warn women taking Candesartan or other ARB medicines about pregnancy risks and the need to stop immediately if pregnancy occurs.
-
Royal College of General Practitioners
Maintain a mandatory prescribing assessment within GP specialty training that assesses prescribing for pregnancy and other special groups.
-
Royal College of General Practitioners
Provide pregnancy-prescribing information resources and links through the RCGP Women’s Health toolkit.
-
Concerns raised1
Failure to scrutinise medication and medication changes
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Free London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Royal Free London NHS Foundation Trust
Update and distribute local adult opioid-toxicity management guidelines, including interim advice based on national best-practice guidance.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Royal Free London NHS Foundation Trust
Expert review concluded that the patient was unlikely to have experienced opioid toxicity, contrary to the concern raised.
-
Concerns raised1
Lack of clinical staff awareness of Clozapine's potential fatal side effects
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Medicines and Healthcare products Regulatory Agency
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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NHS England
Raised clinician awareness of clozapine side effects by communicating associated risks to mental health chief pharmacists and health communities.
-
Medicines and Healthcare products Regulatory Agency
Review clozapine product information and consider whether warnings for healthcare professionals, patients and carers can be clarified.
-
Medicines and Healthcare products Regulatory Agency
Engage relevant stakeholders during the clozapine product-information review to ensure regulatory documents meet patients’ and prescribers’ needs.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Medicines and Healthcare products Regulatory Agency
Commenting on clinical decisions in specific cases, including those concerning clozapine, is outside the respondent’s remit.
-
Concerns raised1
Failure to assess the suitability of Olanzapine depot injections for in-patients who refuse vital signs checks
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Under-appreciation of the risks posed by elevated propranolol medication levels
Linked response
- National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
National Institute for Health and Care Excellence
Complete a surveillance review of current evidence and discuss the findings with GP advisors regarding propranolol guidance.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
National Institute for Health and Care Excellence
The guideline will not be updated at this time because MHRA found no need for a safety communication and noted widespread safe propranolol use.
-
Concerns raised1
Failure to consider the risks of prescribing opioids to patients with former opioid addiction
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS Greater Manchester Integrated Care Board
- Royal College of General Practitioners
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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NHS Greater Manchester Integrated Care Board
Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
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NHS Greater Manchester Integrated Care Board
Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
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Royal College of General Practitioners
Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
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Royal College of General Practitioners
Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
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Concerns raised1
Failure to recognise when patients are receiving Aspirin only
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Cornwall Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Royal Cornwall Hospitals NHS Trust
Implement revised PCI pack wording clarifying provision of Dual Anti-Platelet Therapy.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026