First reported 30 Jul 2013•Latest report 3 Jun 2026
Definition
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.
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.
Reports
54
Distinct published reports
Individual concerns
58
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
100
Described in published responses
Reports over time
Reports 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.
Department of Health and Social Care8
NHS England6
NHS Greater Manchester Integrated Care Board5
Care Quality Commission4
Medicines and Healthcare products Regulatory Agency4
NHS Surrey and Sussex Integrated Care Board3
Royal College of General Practitioners3
Betsi Cadwaladr University LHB2
General Medical Council2
Greater Manchester Health and Social Care Partnership2
Herefordshire and Worcestershire Health and Care NHS Trust2
Nursing and Midwifery Council2
Royal College of Psychiatrists2
Adelaide Medical Centre, London1
Alvaston Medical Centre1
Healthcare site18
NHS trust17
Integrated care board9
Ministerial department8
Executive non-departmental public body7
Health and social care service regulator4
Health professional body4
Local health board4
Medicines and medical devices regulator4
Health and care professional regulator3
Health-system partnership3
Clinical commissioning group2
Multi-service care provider2
Professional body2
Company limited by guarantee1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner South London
Concerns raised1
Insufficiently thorough review of repeat medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement medication reviews for patients without a review for over 12 months, using EMIS searches, clinician prompts, and recall monitoring for higher-risk medicines.
Stated by Bexley Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
Central Hampshire
Concerns raised1
Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Action
Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Action
Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.
Stated by General Medical CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner West London
Concerns raised1
Lack of a system to address harmful medication interactions and redundant treatment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Failure to identify incorrect warfarin prescribing
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Staffordshire South
Concerns raised1
Failure of staff to recognise Clozapine significance, side-effects and warning signs of deterioration
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to recognise opioid sensitivity when prescribing or administering opioids
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Appoint a nurse-qualified Clinical Services Manager to support medication audits and staff training across the homes.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Roll out enhanced refresher training on care-plan documentation, medication administration, and recording residents’ conditions and needs across C&C homes.
Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
Action
Review and further develop medication training with the Quality and Compliance Manager, Clinical Services Manager and Director of Workplace and Culture.
Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
Action
Remind staff to record and check allergies and sensitivities on every admission and discharge, including manual updates to TTA forms and drug charts.
Stated by Royal Free HospitalStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Develop an electronic process with IT and Cerner to record allergy information at admission and transfer it to discharge documentation, including assessing backdating options.
Stated by Royal Free HospitalStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
Action
Introduce EPR/EPMA functionality to populate discharge documentation with allergy status and prompt staff when allergy information is missing.
Stated by Royal Free HospitalStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019.
Action
Discussed appropriate coding of clinically significant opioid sensitivities in GP notes.
Stated by Adelaide Medical Centre, LondonStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Recorded the learning in an internal significant event and shared it with all practice clinicians, including the opioid-sensitivity alerting process.
Stated by Adelaide Medical Centre, LondonStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Care staff cannot diagnose medication allergies or sensitivities and therefore cannot record family concerns in care plans without clinical confirmation.
Stated by Central & Cecil Housing Trust (C&CUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
GPs, treating doctors and hospitals must provide official clinical advice before medication allergies or changes can be recorded and communicated to pharmacists.
Stated by Central & Cecil Housing Trust (C&CRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised1
Failure to apply adequate safeguards when prescribing potentially dependence-forming or misused medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.19
Action
Discuss discharge-information requirements with Emergency Department medical staff through regular governance meetings.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Increase staff awareness of frequent requests for small medication quantities as potential risk indicators.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Audit records of patients receiving Zopiclone and review their prescribed quantities.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Provide protected administrative and clinical staff time to manage prescription requests.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Discuss sharing the high-risk medication review protocol with a linked practice.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Embed the high-risk drug review protocol with support from the Medication Management team.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Ensure the new Practice Repeat Prescribing Policy covers current best practice.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Audit Zopiclone prescribing to verify repeat-template intervals, doses and limits, and reduce some prescription amounts.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Remove online prescription requests for controlled drugs and drugs of potential abuse or dependence, following patient assessment.
Stated by North Laine Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Add patients who overdose to the weekly prescription list.
Stated by North Laine Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 8 July 2018.
Action
Revise the practice prescribing policy using CCG pharmaceutical advice and discuss the updated policy in a whole-practice meeting.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Raise receptionist and GP awareness of patients ordering prescriptions too early, including when requested amounts appear small.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Review patients receiving controlled drugs and agree medication-reduction or cessation plans with them.
Stated by North Laine Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.
Stated by North Laine Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 8 July 2018.
Action
Copy all GPs into reports of overdoses and other suicide attempts.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Action
Code all overdoses and suicide attempts in the practice system.
Stated by North Laine Medical CentreStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.
Gloucestershire
Concerns raised1
Failure to consider concurrent use of additional fentanyl and illicit medication and its effects
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Stated by Gloucestershire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2018.
Cornwall and Isles of Scilly
Concerns raised1
Lack of recognition among emergency medicine professionals of relative opioid toxicity after local anaesthetic nerve block
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Lack of medication review for correct Rivaroxaban dosage and duration
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
