Recurring concern
Failure to identify clinically significant medication risks
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Request correctionFirst reported 30 Jul 2013•Latest report 3 Jun 2026
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
- Individual concerns
- 58
- Date range
- 2013–2026
- Stated actions
- 100
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to recognise the QT-prolonging potential of multiple psychotropic medication
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.4
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Action
Publicise the medication-safety concerns to Royal College of Psychiatrists members and fellows.
Stated by Royal College of Psychiatrists -
Action
Determine how best to raise the medication-safety concerns with old-age psychiatrists.
Stated by Royal College of Psychiatrists -
Action
Review continuing medical education initiatives to ensure comprehensive coverage of the medication-safety issue in College materials.
Stated by Royal College of Psychiatrists
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Action
Review the product information for olanzapine, mirtazapine and indapamide to assess QT-prolongation warnings.
Stated by Medicines and Healthcare products Regulatory Agency
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing product warnings appropriately address QT-prolongation risks, so no regulatory changes are currently proposed.
Stated by Medicines and Healthcare products Regulatory Agency
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Concerns raised1
Failure to assess the significance of patients’ existing comorbidity medication
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to consider medication details and the significance of diclofenac
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of clear, accessible guidance for ward staff on opioid risks and side effects in orthogeriatric patients
Responses linked to these concernsEach 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.2
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Action
Produce staff guidance on opioid medication risks, side effects and signs of opioid toxicity.
Stated by Barts Health NHS Trust -
Action
Cascade opioid-toxicity guidance to ward and medical staff and publish it in the hospital newsletter.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to record and act on Heparin-induced confusion
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Reinforce documenting drug allergies and adverse effects and escalate drug-related issues to senior clinical staff.
Stated by Barts Health NHS Trust
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Concerns raised2
Failure to account for asthma contraindications when prescribing propranolol
Failure to recognise the toxic significance of medication combinations during reception screening
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Provide whole-nursing-team training to recognise medicines requiring ECG referral.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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Concerns raised1
Failure to consider paraffin-emollient fire risk when 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to stop medicines when Methadone toxicity is considered
Failure to assess drug interactions and cumulative effects before prescribing
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate the effects of caffeine and smoking changes on clozapine levels
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of a system to ensure consideration of other prescribed medicines when prescribing tramadol
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026