Recurring concern
Unreliable medication dosage verification and communication
- Reports that mention this concern
- 16
- Times this concern has been raised
- 20
- Stated actions linked to this concern
- 26
What this concern includes
Includes failures of dosage verification, clarification, read-back, discussion or communication when they directly concern medication dosage safety across prescribing, dispensing, administration or transitions of care.
What is not included
- Excludes medication safety concerns unrelated to dosage verification or communication, such as failures to refer for non-medication care.
- Excludes generic staffing, documentation or communication deficiencies that are not directly tied to medication dosage safety.
- Excludes failures concerning medication choice, monitoring or adherence where dosage verification or communication is not the unsafe condition.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 16 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of checking of verbally prescribed drugs before administration
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Establish a working group with Emergency Department and Anaesthetics representation to address emergency intravenous drug administration.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Hold the working group’s scheduled meeting to examine resuscitation-area systems and processes.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Distribute the Intravenous Drugs Administration Policy to all qualified Emergency Department staff.
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Concerns raised1
Failure to discuss with patients the implications of exceeding prescribed dosages
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to ensure medication directions and labels correspond to the prescribed use
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Hillingdon Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
NHS Hillingdon Clinical Commissioning Group
Review processes for recording medications across different healthcare sectors.
-
NHS Hillingdon Clinical Commissioning Group
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
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NHS Hillingdon Clinical Commissioning Group
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
-
Concerns raised1
Lack of a protocol for pharmacist-clinician discussion of queried drug dosages
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Surrey and Sussex Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Surrey and Sussex Healthcare NHS Trust
Issue a directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.
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Surrey and Sussex Healthcare NHS Trust
Reiterate the medication-screening procedure requiring direct discussion between prescribing clinicians and screening or dispensing pharmacists, with escalation to another prescriber when necessary.
-
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.
Linked responses
- Department of Health and Social Care
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Department of Health and Social Care
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
-
NHS England
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
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Concerns raised1
Failure to complete medication reconciliation on admission and pre-assessment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026