Recurring concern
Unreliable medication dosage verification and communication
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Request correctionFirst reported 30 Jul 2013•Latest report 16 Mar 2026
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.
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.
- Reports
- 16
- Individual concerns
- 20
- Date range
- 2013–2026
- Stated actions
- 26
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.
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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.
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
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Action
Establish a working group with Emergency Department and Anaesthetics representation to address emergency intravenous drug administration.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Hold the working group’s scheduled meeting to examine resuscitation-area systems and processes.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Distribute the Intravenous Drugs Administration Policy to all qualified Emergency Department staff.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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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.
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.
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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.
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
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Action
Review processes for recording medications across different healthcare sectors.
Stated by NHS Hillingdon Clinical Commissioning Group -
Action
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Stated by NHS Hillingdon Clinical Commissioning Group -
Action
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Stated by NHS Hillingdon Clinical Commissioning Group
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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.
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
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Action
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.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Reiterate the medication-screening procedure requiring direct discussion between prescribing clinicians and screening or dispensing pharmacists, with escalation to another prescriber when necessary.
Stated by Surrey and Sussex Healthcare NHS Trust
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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.
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.2
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Position
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Stated by Department of Health and Social Care
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Position
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
Stated by NHS England
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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.
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.
Data last updated 7 September 2026