Recurring concern
Unreliable clinician management of medication side effects
Pin
Get email alerts
Request correctionFirst reported 12 Oct 2013•Latest report 3 Jun 2026
What this concern includes
Includes failures in clinician-facing processes for identifying, enquiring about, recording, communicating, reviewing or escalating medication side effects, including unclear recording guidance and inadequate awareness of required escalation procedures.
Not included
- Excludes patient-facing medication counselling or warnings where the clinician-facing recognition, recording or escalation process is not deficient.
- Excludes prescribing, dispensing, administration, monitoring or treatment failures that do not specifically concern recognising or responding to medication side effects.
- Excludes generic clinical documentation, training or communication deficiencies unless they directly impair medication-side-effect management.
- Excludes side effects from non-medication treatments unless the assertion explicitly concerns medication side effects.
- Reports
- 11
- Individual concerns
- 15
- Date range
- 2013–2026
- Stated actions
- 10
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
Lack of standardised guidance for recording answers about possible medication side effects
Lack of standardised guidance for asking questions about possible medication side effects
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
Use the Clozapine Clinic standard operating procedure and GASS to monitor and record clozapine side effects in electronic patient records.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust -
Action
Re-issue the Clozapine Treatment Guidelines and clinic guidance to the mental health clinical workforce.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust -
Action
Undertake follow-up to ensure newly appointed and existing staff are aware of and comply with both clozapine guidance documents.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
-
Concerns raised1
Limited clinician awareness of nitrofurantoin pulmonary damage and respiratory failure in elderly patients
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of clinical staff awareness of Clozapine's potential fatal side effects
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
Raised clinician awareness of clozapine side effects by communicating associated risks to mental health chief pharmacists and health communities.
Stated by NHS England -
Action
Review clozapine product information and consider whether warnings for healthcare professionals, patients and carers can be clarified.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Engage relevant stakeholders during the clozapine product-information review to ensure regulatory documents meet patients’ and prescribers’ needs.
Stated by Medicines and Healthcare products Regulatory Agency
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Commenting on clinical decisions in specific cases, including those concerning clozapine, is outside the respondent’s remit.
Stated by Medicines and Healthcare products Regulatory Agency
-
Concerns raised1
Lack of a single reference point for identifying medications that increase suicidal behaviour
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Prescribers are responsible for using the Summary of Product Characteristics to prescribe medicines safely.
Stated by Department of Health and Social Care
-
Concerns raised1
Lack of prescribing doctors’ awareness of the potential rare side effect
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Under-appreciation of clozapine side effects relating to smoking and pneumonia
Insufficient BNF clarity about clozapine side effects
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 GP awareness of escalation procedures for medication side effects
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.
-
Concerns raised3
Failure of liaison between dermatologists and other consultants about Hydroxychloroquine toxicity
Lack of awareness of Hydroxychloroquine toxic accumulation at recommended doses
Lack of awareness among psychiatrists of Hydroxychloroquine mental and toxic side-effects
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.1
-
Action
Seek expert pharmacovigilance advice on available evidence concerning hydroxychloroquine toxicity and the reported death.
Stated by Medicines and Healthcare products Regulatory Agency
-
Concerns raised1
Lack of clear, accessible guidance for ward staff on opioid risks and side effects in orthogeriatric patients
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
Produce staff guidance on opioid medication risks, side effects and signs of opioid toxicity.
Stated by Barts Health NHS Trust -
Action
Cascade opioid-toxicity guidance to ward and medical staff and publish it in the hospital newsletter.
Stated by Barts Health NHS Trust
-
Concerns raised1
Lack of prescriber awareness of Gabapentin's rare side effect of precipitating diabetic coma
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
Build the drug-safety review into day-to-day clinical practice.
Stated by Guy'S and St Thomas' NHS Foundation Trust
Data last updated 7 September 2026