Recurring concern
Unreliable electronic medication-system controls for safe prescribing and administration
- Reports that mention this concern
- 6
- Times this concern has been raised
- 7
- Stated actions linked to this concern
- 5
What this concern includes
Includes failures of electronic medication systems or their dedicated medication workflows that affect medication units, concentrations, strengths, conversions, pre-populated values, selectable prescribing choices or other system controls directly governing safe prescribing or administration.
What is not included
- Excludes generic electronic-record failures where the concern is access to or communication of clinical information rather than a medication-system control.
- Excludes medication prescribing, dispensing or administration errors where no electronic medication-system deficiency is identified.
- Excludes generic software usability or configuration problems unrelated to medication safety.
- Excludes failures limited to reviewing, communicating or acting on medication information after the electronic medication system has operated as intended.
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 6 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to ensure safe and clearly understood medication-system operation
This report raised 8 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.
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Concerns raised1
Lack of system warnings identifying pregnancy during repeat prescribing
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Riverview Surgery
Stated actions 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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Riverview Surgery
Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.
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Riverview Surgery
Review all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.
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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Riverview Surgery
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
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Concerns raised1
Risk of loss or dilution of prescribing safety nets during electronic system changes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Lewisham and Greenwich NHS Trust
- Medicines and Healthcare products Regulatory Agency
Stated actions 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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Medicines and Healthcare products Regulatory Agency
Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.
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Lewisham and Greenwich NHS Trust
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
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Concerns raised2
Failure to ensure accurate patient weights are entered before paracetamol prescribing
Absence of electronic alerts for weight accuracy and liver-toxicity risk in oral paracetamol prescribing
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Bedfordshire Hospitals 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
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Bedfordshire Hospitals NHS Foundation Trust
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
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Concerns raised1
Unavailability of an appropriate morphine strength as a prescribing choice on EMIS
This report raised 4 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.
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Concerns raised1
Failure of the electronic prescribing system to require a secondary medication-selection check
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Birmingham NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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University Hospitals Birmingham NHS Foundation Trust
Additional prescribing double-checks are unlikely to improve safety and may increase risk through alert fatigue.
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University Hospitals Birmingham NHS Foundation Trust
Existing EPMA systems and processes sufficiently minimise medication risk, so no additional prescribing double-check is introduced.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026