Recurring concern
Unreliable review and monitoring of repeat prescriptions
Pin
Get email alerts
Request correctionFirst reported 26 Mar 2014•Latest report 2 Feb 2026
What this concern includes
Includes failures in the repeat-prescription review and monitoring process, including detailed scrutiny before approval, review against applicable guidance, regular monitoring of ongoing repeat medication, consideration of relevant patient circumstances and follow-up of continued prescribing.
Not included
- Excludes medication-quantity controls where the specific concern is excessive supply or transaction limits without a repeat-prescription review or monitoring failure.
- Excludes prescribing, dispensing, administration or supply failures unrelated to repeat prescriptions or their review and monitoring.
- Excludes long-term medication reviews where repeat prescribing is not the supported process boundary.
- Excludes failures to obtain patient wishes before a pharmacist requests a repeat prescription unless the assertion also identifies deficient clinical review or monitoring of the repeat prescription.
- Excludes generic electronic-record, staffing, documentation or communication deficiencies unless they directly impair repeat-prescription review or monitoring.
- Reports
- 14
- Individual concerns
- 18
- Date range
- 2014–2026
- Stated actions
- 36
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.
-
Concerns raised2
Failure to conduct a detailed review of repeat prescription requests
Lack of system warnings identifying pregnancy during repeat 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.
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
-
Action
Increase reviews of women of childbearing age prescribed ARB medicines from six-monthly to three-monthly.
Stated by Riverview Surgery -
Action
Use reception tasks to trigger pregnancy coding, midwife referral checks and medication reviews, with duty-GP cover when unavailable.
Stated by Riverview Surgery -
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
-
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
-
Concerns raised2
Continued prescribing of repeat medications in large amounts at 28-day frequency after overdose disclosure
Failure to conduct medication reviews after overdose disclosures and related concerns
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.
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.3
-
Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCN -
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCN -
Action
Expand the annual proactive self-harm follow-up audit to record medication reviews and discussions about prescribed medication quantities.
Stated by Your Health Partnership PCN
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
NICE Quality Standard 34 does not specifically require medication review following self-harm.
Stated by Your Health Partnership PCN
-
Concerns raised1
Lack of medication review controls for repeat prescriptions to vulnerable patients with histories of addiction, self-harm, suicidal ideation or prescription medication overdose
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
-
Action
Audit all registered patients coded at risk of self-harm or suicide and receiving repeat medication, complete medication and risk reviews, and restrict repeats to seven-day supplies.
Stated by Addison House & Barbara Castle Surgery -
Action
Update the Polypharmacy and High-Risk Prescribing Policy to require pharmacist review of relevant correspondence, seven-day high-risk medication supplies, and three-monthly or earlier reviews for high-risk patients.
Stated by Addison House & Barbara Castle Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The practice disputes that no safety controls existed, stating its repeat prescribing policy already contained restrictions for inappropriate high-risk medication requests.
Stated by Addison House & Barbara Castle Surgery
-
Concerns raised2
Inadequate specialist input for patients prescribed multiple analgesics on repeat prescription
Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics
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.5
-
Action
Provide support and set expectations for clinical pharmacists working in general practice.
Stated by Department of Health and Social Care -
Action
Use medicines-optimisation support to identify, categorise and prioritise patients receiving repeat prescriptions for multiple analgesics.
Stated by Donneybrook Medical Centre -
Action
Review patients on the red, amber and green priority lists, including checking previous reviews and recording required follow-up dates.
Stated by Donneybrook Medical Centre
-
Action
Limit prescription durations according to risk category and automatically arrange GP review when prescriptions become due.
Stated by Donneybrook Medical Centre -
Action
Maintain a safety-netting system recording review dates and run monthly searches to identify new patients requiring inclusion.
Stated by Donneybrook Medical Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
ICBs are responsible for commissioning specialist pain clinic services appropriate to their populations.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure to scrutinise repeat prescription requests
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.
-
Concerns raised1
Lack of adequate monitoring of repeat medication
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.6
-
Action
Carry out structured medication reviews for patients at increased risk of medication-related harm.
Stated by NHS England -
Action
Support medicines optimisation through the Medicines Value Programme, including reducing use of clinically or cost-ineffective medicines.
Stated by NHS England -
Action
Undertake a review of NHS over-prescribing and produce recommendations to reduce overprescribing and medicines wastage.
Stated by NHS England
-
Action
Operate the Medicines Safety Improvement Programme to reduce medication-related harm, focusing on high-risk drugs, situations and vulnerable patients.
Stated by NHS England -
Action
Publish dementia care pathway guidance recommending medication review and management, including monitoring and review resources.
Stated by NHS England -
Action
Refresh personalised dementia care and support planning guidance to emphasise medication reviews and appropriate medication access, continuation or cessation.
Stated by NHS England
-
Concerns raised1
Insufficiently thorough review of repeat medication
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
-
Action
Implement medication reviews for patients without a review for over 12 months, using EMIS searches, clinician prompts, and recall monitoring for higher-risk medicines.
Stated by Bexley Medical Group
-
Concerns raised1
Failure to regularly monitor patients prescribed medication that could be dangerous to their welfare
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.
-
Concerns raised2
Failure to conduct timely and sufficiently informed medication reviews for long-term repeat prescriptions
Inadequate recording of medication reviews and reasons for repeat prescribing
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.
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
-
Action
Refer controlled-drug prescribing and medication-review issues for national review and a decision on whether guidance requires amendment.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Annual medication reviews were considered unlikely to have prevented this death, which resulted primarily from the patient's decision not to seek medical advice.
Stated by NHS England
-
Position
The national prescribing team will decide whether guidance on controlled-drug prescriptions requires amendment.
Stated by NHS England
-
Concerns raised1
Lack of procedures to monitor and manage repeat prescriptions exceeding prescribed dosages
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.
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
Identify patients prescribed tramadol and other potentially harmful medicines, review prescribing indications, doses and issue patterns, and recommend contact, early review or no change.
Stated by Manor Field Surgery -
Action
Convert electronic prescriptions to paper prescriptions requiring doctor review before signing.
Stated by Manor Field Surgery -
Action
Seek medicines-management, drugs-and-alcohol, and pharmacist input on difficult or potentially problematic prescriptions.
Stated by Manor Field Surgery
-
Action
Call patients identified as potential over-users of tramadol for early review.
Stated by Manor Field Surgery -
Action
Complete a thorough review of medication ordering and review procedures to identify safety problems.
Stated by Manor Field Surgery -
Action
Change repeat-prescribing policy for all medicines and implement amended repeat-prescribing and acute-prescribing protocols with strengthened electronic prompts and consultation processes.
Stated by Manor Field Surgery -
Action
Explain the amended prescribing protocols and procedures to all practice staff during protected time within 10 days.
Stated by Manor Field Surgery
Data last updated 7 September 2026