Recurring concern

Failure to verify medication and dose before dispensing

First to latest report 27 Jan 2014 — 17 Dec 2025

Reports that mention this concern: 4
Times this concern has been raised: 4
Stated actions linked to this concern: 9

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.

What is 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.

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

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

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

17 Dec2025
Sunderland
Concerns raised1
1. 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.
Linked response

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Stated actions 7
1. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
2. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
3. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
1. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Revise nursing medicines competency assessment requirements covering EPMA, Omnicell, formulations, liquid disposal, supervision scenarios and medicines-administration sequencing.
2. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
3. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
4. Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
  Develop educational and instructional videos supporting Omnicell use.
AI-generated summary

Valerie Jane Gibson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Valerie Jane Gibson died on 29 October 2023 at Monkwearmouth Hospital after being admitted under the Mental Health Act with psychotic symptoms and assessed as being at risk of self-harm and harm to others. The principal concerns were uncertainty and inconsistency in the checking of possessions, dispensing and administration of medication, supervision of nurses, and use of the Omnicell and electronic medication record systems, resulting in unclear records of what medication had been dispensed or administered.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on manual identification and entry of prescribed medication into the Omnicell
Wider context from the report
“It was apparent that the Omnicell and electronic medication record (ePMA) are two distinct and separate systems that are supposed to be used alongside each other but the evidence highlighted the potential flaws in that approach due to the reliance on the person using the system adopting the correct approach. I was shocked that the Omnicell did not refer to a patient’s prescribed medication and relies on the nurse dispensing to have correctly identified from the patient’s electronic record (ePMA) the correct prescription and then inputting the correct medication and dose to the Omnicell. Differing amounts were inputted in and on 28th October 2023 and stock levels of the non-prescribed liquid medication showed a significantly large reduction which was over 3 times a normal dose with no evidence a spillage had occurred and no incident report completed. In addition, small doses were inputted to enable the medication to be returned to the cabinet if the door had shut before the nurse had replaced the bottle. This led to complete confusion over stock levels, what had been dispensed and whether it had been disposed of or administered to the patient. ”
Source location
Valerie Jane Gibson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.

Verbatim wording from the response
“- An alert on the Trusts Access Request Management System (ARMS) has been established to alert ward-based pharmacy teams whenever a new member of Trust nursing staff commences employment so that face to face Omnicell training can be delivered during their induction period.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.

Verbatim wording from the response
“- Ward based pharmacy teams have received updated face to face Omnicell training, this updated training has also been offered to nursing teams across bed based services.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.

Verbatim wording from the response
“- Omnicell guides and training checklists have been updated and are available to all staff on the Trust intranet and have been circulated via the Trust bulletin.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise nursing medicines competency assessment requirements covering EPMA, Omnicell, formulations, liquid disposal, supervision scenarios and medicines-administration sequencing.

Verbatim wording from the response
“- Nursing staff medicines competencies have been reviewed and updated to include use of EPMA and Omnicell.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.

Verbatim wording from the response
“- The Trust Medicines Optimisation Policy and medicines management e-learning package have also received updates related to Omnicell task competencies and use of EPMA, policy updates have been circulated to staff via the Trust policy bulletin.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.

Verbatim wording from the response
“- In addition to the above, a Task and Finish group has been established to develop further actions and initiatives related to safer practice in medicines administration. The group met initially on 22/1/2026 and are scoping:”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 2 · response
Published 19 December 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop educational and instructional videos supporting Omnicell use.

Verbatim wording from the response
“In relation to this finding the Trust has added a segment to its medication administration e-learning package around the ‘Rights of Medication Administration’. A poster for display in clinics / dispensing areas has also been produced to raise awareness. In addition, the review of the medicine’s competency assessment will include a section on the correct sequencing involved in medicines administration. The Trust Pharmacy service is also in the process of developing educational / instructional videos to support the use of Omnicell.”

Source location
Response from Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Page 5 · response
Published 19 December 2025
Open published response
18 Aug2023
Inner South London
Concerns raised1
1. 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.
Linked response

NHS England
Stated actions 2
1. NHS England
  Undertake further actions and discussions after receiving the paediatric medicines review’s statement on next steps.
2. NHS England
  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.
AI-generated summary

Juanita Boate Nti · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Juanita Boate Nti had complex congenital diseases and was receiving palliative care at home. She received twenty times the intended morphine dose after the prescription and symptom control plan failed to clearly specify the volume, and the prescription contained two different concentrations. She suffered respiratory arrest and died following an accidental morphine overdose, with concerns also identified about the EMIS prescribing system not offering the relevant morphine strength.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to identify conflicting medication concentration and specify administration volume before dispensing
Wider context from the report
“The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”. The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms. Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety. ”
Source location
Juanita Boate Nti · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Undertake further actions and discussions after receiving the paediatric medicines review’s statement on next steps.

Verbatim wording from the response
“The national Patient Safety Team at NHS England are aware of the issues and the Royal College of Paediatrics and Child Health (RCPCH) and the Neonatal and Paediatric Pharmacy Group (NPPG) Joint Medicines Committee is currently undertaking a ‘Review of the Management of the Supply of Unlicensed Liquid Medicines to Children’, which includes the workstreams referenced above. NHS England awaits a statement from the Group as to next steps later in November 2023, and further actions and discussions will then take place. We can update the Coroner once we have an update.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
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.

Verbatim wording from the response
“The London region Controlled Drugs Accountable Officer will also be discussing this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans which will include communications to GPs and community pharmacists.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response
30 Apr2017
Birmingham and Solihull
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ahshiyah Bibi · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of nursing staff to check dispensed insulin doses
Wider context from the report
“2. At 04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead of a 10 unit dose, the error was identified when she had received 20 units and the infusion was stopped. The evidence of ████████ who prescribed the insulin was she knew the Trust’s protocol and standard treatment to be a dose of 10 units but made a mistake. It appears from investigations carried out by ████████ that the two members of the nursing staff who dispensed the dose did not check the dose. Professor Hanif, Consultant in Diabetes, gave independent expert evidence that in his view there is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia. Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia. ████████ agreed that the fact she more commonly prescribes a 50 unit dose of insulin for hyperglycaemia probably did explain her error. ”
Source location
Ahshiyah Bibi · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jan2014
York City
Concerns raised1
1. 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.
Linked responses

Department of Health and Social Care
NHS England
Respondent positions 2
1. Department of Health and Social Care
  NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
  Redirects responsibility
1. NHS England
  Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
  Unable to act
AI-generated summary

Judith Lesley Marshall · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of mandatory read-back procedures for dispensing details
Wider context from the report
“(4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules. ”
Source location
Judith Lesley Marshall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.

Verbatim wording from the response
“As Secretary of State for Health, I am responsible for setting national priorities, monitoring the whole system’s performance and supporting the integrity of the system to protect the best interests of patients, the public and the taxpayer. Since 1 April 2013, most day to day decisions are taken by NHS England. NHS England is responsible for commissioning primary care services, including pharmaceutical services.”

Source location
2014-0039-Response-by-Department-of-Health
Page 2 · response
Published 27 January 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.

Verbatim wording from the response
“4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist correctly had the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.”

Source location
2014-0039-Response-by-NHS-England
Page 3 · response
Published 27 January 2014
Open published response