First reported 27 Jan 2014•Latest report 17 Dec 2025
Definition
What this concern includes
Includes failures in controls that verify the medication and dose selected or entered for dispensing against the patient's current prescription, including manual transcription or cabinet-entry checks and independent checks of dispensed doses.
Not included
Excludes failures limited to medication prescribing decisions when no dispensing verification failure is identified.
Excludes medication storage, stock reconciliation, supply, administration or monitoring failures where medication identity and dose were reliably verified before dispensing.
Excludes failures involving unrelated clinical records or electronic systems unless they directly cause medication or dose verification to fail.
Excludes medication-specific guidance or clinical review concerns that do not involve verification of the medication and dose selected for dispensing.
Reports
4
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
9
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.
NHS England2
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Department of Health and Social Care1
General Pharmaceutical Council1
Royal Pharmaceutical Society of Great Britain1
University Hospitals Birmingham NHS Foundation Trust1
Executive non-departmental public body2
NHS trust2
Health and care professional regulator1
Health professional body1
Ministerial department1
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.
Sunderland
Concerns raised1
Reliance on manual identification and entry of prescribed medication into the Omnicell
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.7
Action
Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Develop educational and instructional videos supporting Omnicell use.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Inner South London
Concerns raised1
Failure to identify conflicting medication concentration and specify administration volume before dispensing
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.
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
Action
Undertake further actions and discussions after receiving the paediatric medicines review’s statement on next steps.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Action
Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Birmingham and Solihull
Concerns raised1
Failure of nursing staff to check dispensed insulin doses
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.
York City
Concerns raised1
Lack of mandatory read-back procedures for dispensing details
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 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.2
Position
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in controls that verify the medication and dose selected or entered for dispensing against the patient's current prescription, including manual transcription or cabinet-entry checks and independent checks of dispensed doses.
