First reported 12 Oct 2013•Latest report 1 Apr 2026
Definition
What this concern includes
Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
Not included
Excludes failures to act on a clearly received alert where the alerting system itself operated as intended.
Excludes non-clinical alert systems such as police, custody, safeguarding or transport systems unless the report directly concerns a clinical safety-alert system.
Excludes generic record-keeping or communication deficiencies that are not specifically tied to the reliability of a clinical safety alert.
Reports
53
Distinct published reports
Individual concerns
56
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
66
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 England12
Department of Health and Social Care11
Egton Medical Information Systems Limited3
Medicines and Healthcare products Regulatory Agency3
Barts Health NHS Trust2
Care Quality Commission2
Great Western Hospitals NHS Foundation Trust2
Medway NHS Foundation Trust2
NHS Wales2
Proprietary Association of Great Britain2
Royal College of General Practitioners2
Royal Cornwall Hospitals NHS Trust2
Welsh Government2
Adelaide Medical Centre, London1
Alliance Pharmaceuticals Limited1
NHS trust27
Executive non-departmental public body13
Healthcare site13
Ministerial department11
Private limited company6
Health professional body5
Medicines and medical devices regulator3
Company2
Devolved government2
Health and social care service regulator2
Health-system partnership2
Social-care provider2
Trade association2
Community interest company1
Health and care professional regulator1
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.
Worcestershire
Concerns raised1
Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms
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.
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
Engage the MHRA to establish the manufacturer’s position and understand how alarm-latching functionality should be managed clinically.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The MHRA is the appropriate authority to advise healthcare organisations on medical-device concerns involving alarm-latching capabilities.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Failure of the patient records management system to accurately highlight important information for patient care and treatment
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.2
Action
Consider adding an explicit CAA bleeding-risk prompt to the VTE assessment tool through the Thrombosis Committee and embed any agreed change in Trust guidelines.
Stated by West Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Action
Develop the safer handovers quality-improvement project to improve highlighting of essential information during nurse-to-nurse transfers.
Stated by West Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An automated CAA anticoagulation alert cannot be implemented because eCare lacks the necessary functionality and reliable evidence base.
Stated by West Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Sunderland
Concerns raised1
Lack of system warnings identifying pregnancy during repeat prescribing
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.
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
Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.
Stated by Riverview SurgeryStated plannedThe respondent said that this action was planned when they made their response on 2 February 2026.
Action
Review all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.
Stated by Riverview SurgeryStated completedThe respondent said that this action was complete when they made their response on 2 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
Stated by Riverview SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Wales Central
Concerns raised1
Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy
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.
Surrey
Concerns raised2
Failure of nitrofurantoin safety alert criteria to cover patients without pre-existing pulmonary disease
Failure of the surgery EMIS system to display MHRA nitrofurantoin safety alerts
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing EMIS Web functionality is considered sufficient to mitigate the specific MHRA Nitrofurantoin risk; no further software development is required.
Stated by OptumExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bedfordshire and Luton
Concerns raised1
Absence of electronic alerts for weight accuracy and liver-toxicity risk in oral paracetamol prescribing
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.1
Action
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure of prescribing software to trigger alerts for the interaction between amitriptyline, paroxetine and ivabradine
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Prescribing software alerts are determined by independent commercial providers, which choose the reference materials informing alert content.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cornwall and Isles of Scilly
Concerns raised1
Absence of a digital alert for the need to implement sepsis six
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.
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
Develop a sepsis alert within the new e-Care system to digitally flag when the sepsis six should be actioned.
Stated by Royal Cornwall Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The current NerveCentre system cannot support a digital sepsis alert, although an alert is planned for the replacement EPR system.
Stated by Royal Cornwall Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Lack of a clear and obvious suicide-risk alert in children’s medical records
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers its needs-based risk assessment and reduction process sufficient, so will not introduce a binary suicide-risk flag.
Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex, Brighton and Hove
Concerns raised1
Failure of the medication-ending alert system to draw attention to prescription review when no prescribing clinician accesses the patient’s record
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
Explore with Royal Surrey whether configuration or other changes could facilitate adherence to the clinical workflow, including broadening alert recipients.
Stated by Oracle Corporation UK LimitedStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
Action
Discuss with Royal Surrey establishing an alert-notifications committee to review existing alerts and identify new alerts for development.
Stated by Oracle Corporation UK LimitedStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
Action
Engage Oracle Corporation UK Limited on the electronic prescribing alerting concerns raised in the Report.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
Action
Consider incorporating a test script addressing the prescribing alerting issue into future ePRaSE iterations.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 20 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
No evidence indicates a software defect; Millennium was working as designed and configured, including subsequent independent modifications.
Stated by Oracle Corporation UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Alerts are appropriately displayed within patient records and cannot substitute for clinicians following established clinical workflows and standards of care.
Stated by Oracle Corporation UK LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Login-based or external email alerts are considered unworkable because they risk alert fatigue, workflow disruption, lost acknowledgement monitoring and data-security breaches.
Stated by Oracle Corporation UK LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The client retains responsibility for deciding whether to adopt code or configuration enhancements, including their clinical and commercial implications.
Stated by Oracle Corporation UK LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
