Recurring concern
Unreliable electronic medication-system controls for safe prescribing and administration
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Request correctionFirst reported 26 Oct 2021•Latest report 7 Apr 2026
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.
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.
- Reports
- 6
- Individual concerns
- 7
- Date range
- 2021–2026
- Stated actions
- 5
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 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.
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 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.
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
Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.
Stated by Riverview Surgery -
Action
Review all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.
Stated by Riverview Surgery
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
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
Stated by Riverview Surgery
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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.
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
Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Stated by Lewisham and Greenwich NHS Trust
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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.
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
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Stated by Bedfordshire Hospitals NHS Foundation Trust
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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.
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 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.
Responses linked to these concernsEach 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.2
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Position
Additional prescribing double-checks are unlikely to improve safety and may increase risk through alert fatigue.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Position
Existing EPMA systems and processes sufficiently minimise medication risk, so no additional prescribing double-check is introduced.
Stated by University Hospitals Birmingham NHS Foundation Trust
Data last updated 7 September 2026