First reported 13 Dec 2008•Latest report 19 Mar 2026
Definition
What this concern includes
Includes failures dedicated to reconciling, verifying, correlating, transferring or maintaining a patient’s medication information across clinical records or transitions of care, including medication lists, problem lists, admission or discharge records, community-to-hospital records and medication administration documentation.
Not included
Excludes generic failures in documentation, communication, staffing or clinical review that are not specifically tied to medication reconciliation.
Excludes medication prescribing or administration errors unrelated to an information-reconciliation failure.
Excludes reconciliation of non-medication items, such as property, race participants or general patient accounts.
Excludes failures concerning a different named safety system or hazard unless the report directly identifies medication reconciliation as the unsafe process.
Reports
18
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
39
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.
NHS England3
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bow School1
Bristol NHS Foundation Trust1
Bromley by Bow Health Centre1
Cardiff & Vale University LHB1
Care Quality Commission1
Carewatch (Mid Bucks)1
Chesterfield Royal Hospital NHS Foundation Trust1
Coastal Homecare – Hove Branch1
Compass Wellbeing Tower Hamlets1
Department of Health and Social Care1
Good Hope Hospital1
Greater Manchester Mental Health NHS Foundation Trust1
NHS trust12
Healthcare site4
Executive non-departmental public body3
Domiciliary care provider2
Devolved government1
Health and social care service regulator1
Health professional body1
Health-system partnership1
Integrated care board1
Local health board1
Maintained school1
Medicines and medical devices regulator1
Ministerial department1
Multi-service care provider1
Private limited company1
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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
This report raised 7 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.7
Action
Complete a formal review of the MAR chart SOP for UCR and Home First services.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to scrutinise prescribed medication and medication-system information
This report raised 18 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.4
Action
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Lack of a mechanism for consistently recording pre-admission over-the-counter medications
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 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.4
Action
Amend Emergency Department and ambulance handover documentation to prompt recording of over-the-counter medicines.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Review medicines-reconciliation policies and checklists to clarify discussion and documentation of over-the-counter medicines and ambulance handover information.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Create a Medicines Reconciliation Quick Reference Guide for Emergency Department staff covering information sources and over-the-counter medicine prompts.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Assess options for adding over-the-counter medicine prompts and fields to iCare pharmacy medication-history processes.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Manchester South
Concerns raised1
Unclear responsibility and system for reconciling community and hospital medications
This report raised 8 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Lack of routine cross-referencing between prescribed and collected medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Avon
Concerns raised2
Insufficient pharmacist capacity and medicines reconciliation checking
Failure of hospital medication systems to exchange information, requiring manual transcription during ICU transfers
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
Apply a doctor’s second check when prescribers complete ward drug charts.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Action
Provide routine training for junior and rotational ward pharmacists receiving intensive-care step-down patients.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Action
Implement Careflow Medicines Management across most clinical areas to standardise prescribing and support electronic medicines reconciliation and medication-error controls.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
Action
Review pharmacy funding requests and relevant Trust risk-register entries to provide assurance about medicines-reconciliation safety.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 September 2023.
Action
Invest in additional adult intensive-care pharmacy staff to provide trained-individual medicines reconciliation five days weekly and weekend safety-net reviews.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 September 2023.
Action
Provide a designated quiet space for medication transcription.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Action
Participate in regional auditing to share learning and identify opportunities to reduce medication errors during intensive-care step-down.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A unified electronic prescribing system cannot be introduced because ward and intensive-care systems have incompatible specialised requirements.
Stated by Bristol NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Interoperability between prescribing systems cannot be achieved because it requires technical input from competing external providers outside the Trust’s control.
Stated by Bristol NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Derby and Derbyshire
Concerns raised1
Failure to identify non-receipt of prescribed tinzaparin during transfer of care
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure to identify and continue prescribed antidepressant treatment on admission
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to identify pre-hospital opiate doses and unit discrepancies
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised1
Failure to correlate the medication list with the active problem list
This report raised 5 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures dedicated to reconciling, verifying, correlating, transferring or maintaining a patient’s medication information across clinical records or transitions of care, including medication lists, problem lists, admission or discharge records, community-to-hospital records and medication administration documentation.
