Recurring concern
Unreliable clinical safety-alert systems
- Reports that mention this concern
- 53
- Times this concern has been raised
- 56
- Stated actions linked to this concern
- 66
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.
What is 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.
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 53 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Absence of electronic-record alerts for required medication discrepancy reviews
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Medway 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.1
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Medway NHS Foundation Trust
Develop auditable electronic prescribing functionality that alerts doctors when pharmacists identify issues requiring review.
-
Concerns raised1
Failure to maintain coded overdose alerts in patient records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Green Porch Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Green Porch Medical Centre
Employ a full-time read-coder to ensure correspondence is read-coded and necessary patient alerts are added.
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Green Porch Medical Centre
Implement patient-record alerts that display relevant safety concerns at login until acknowledged.
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Green Porch Medical Centre
Encourage clinicians to use Arden depression-review templates incorporating self-harm questions and automatic risk alerts.
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Green Porch Medical Centre
Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.
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Green Porch Medical Centre
Audit Docman for coding, document routing, follow-up completion and escalation of concerns, with audits every three months.
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Concerns raised1
Failure to place alerts or flags on records about patient complexities and risks
This report raised 6 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 of the Lorenzo electronic system to trigger alerts for markedly raised D-dimer results
This report raised 2 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 review medical-record alerts
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- North London 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.1
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North London NHS Foundation Trust
Review and update the Carenotes alert process, including agreed wording protocols linked to risk-assessment and suicide-prevention processes.
-
Concerns raised1
Lack of an effective national procedure for circulating Patient Alerts to pharmacies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NHSEI is responsible for systems oversight of controlled-drug management and use, including the alert system’s operation.
-
Concerns raised1
Failure of the EMIS computer medical record to alert the medical centre to prior GP registration
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of patient-specific sequential scan data storage and sonographer alerts
This report raised 5 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
Absence of alerts for requested tests to the final decision maker
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
the Shrewsbury and Telford Hospital NHS Trust
The alert facility existed; failure to complete it was attributed to human factors rather than a system failure.
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Concerns raised1
Failure of the alert algorithm to provide earlier differentiation between detached-lead artefacts and life-threatening ventricular defibrillation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- GE Healthcare
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
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GE Healthcare
Implement escalating ECG technical alarms for “Arrhythmia Paused” and “Leads Off” states, including configurable escalation to a high-priority alarm.
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GE Healthcare
Implement improved ventricular fibrillation detection using spectral analysis, faster alarm processing and data from all available ECG leads.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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GE Healthcare
The automated ECG arrhythmia detection algorithm operated within specifications and industry standards; signal conditions and rare rhythm prevented the alarm.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026