First reported 25 Jun 2015•Latest report 25 Nov 2021
Definition
What this concern includes
Includes failures of controls intended to compare, reconcile, flag or escalate discrepancies between prescribed medication and medication recorded as administered, including discrepancies during discharge or care transitions and failures to detect differences between prescription and administration records.
Not included
Excludes general medication reconciliation, prescribing, administration or discharge-medication failures where no discrepancy-detection or checking failure is identified.
Excludes failures to act on a discrepancy after it has been reliably detected when the detection process itself was adequate.
Excludes medication dosage, quantity, supply or adherence concerns that do not involve detecting a discrepancy between prescribed and administered medication.
Excludes generic record-keeping, staffing or communication deficiencies unless they directly impair medication-discrepancy detection.
Reports
2
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2015–2021
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.
Good Hope Hospital1
John Radcliffe Hospital1
Oxford University Hospitals NHS Foundation Trust1
University Hospitals Birmingham NHS Foundation Trust1
Healthcare site2
NHS trust2
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.
Berkshire
Concerns raised1
Lack of a system for flagging discrepancies between drug prescription and administration
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
Include automated drug prescription-to-administration specifications in the future single clinical system procurement.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2021.
Action
Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.
Stated by Oxford University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Matching prescriptions to constantly adjusted infusion rates is impractical in critical care because bedside rates frequently change.
Stated by Oxford University Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Birmingham and Solihull
Concerns raised2
Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation
Lack of a protocol for easily checking medication discrepancies
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
Amend the nursing discharge checklist to remind staff to check the PEPMAC.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
Action
Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
Action
Obtain governance approval and pilot the revised yellow-card documentation within palliative care.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 June 2015.
Action
Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 June 2015.
Action
Check available MAC charts and TTOs for medication discrepancies.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 June 2015.
Action
Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 June 2015.
Action
Review existing pharmacy SOPs to ensure they are robust and fit for purpose.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2015.
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Includes failures of controls intended to compare, reconcile, flag or escalate discrepancies between prescribed medication and medication recorded as administered, including discrepancies during discharge or care transitions and failures to detect differences between prescription and administration records.
