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.
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
Reports and published responses 53 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
NHS England
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
NHS England
Engage the MHRA to establish the manufacturer’s position and understand how alarm-latching functionality should be managed clinically.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
The MHRA is the appropriate authority to advise healthcare organisations on medical-device concerns involving alarm-latching capabilities.
Redirects 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.
Linked response
West Suffolk 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.2
West Suffolk NHS Foundation Trust
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.
West Suffolk NHS Foundation Trust
Develop the safer handovers quality-improvement project to improve highlighting of essential information during nurse-to-nurse transfers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
West Suffolk NHS Foundation Trust
An automated CAA anticoagulation alert cannot be implemented because eCare lacks the necessary functionality and reliable evidence base.
Unable 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.
Linked response
Riverview Surgery
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
Riverview Surgery
Add pregnancy-stop warnings to electronic prescribing instructions so they appear on pharmacy-printed medication labels.
Riverview Surgery
Review all women of childbearing age taking ARB medicines and add prescription alerts advising immediate cessation and GP consultation if pregnancy occurs.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Riverview Surgery
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
Unable 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.
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.
Linked response
Optum
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Optum
Existing EMIS Web functionality is considered sufficient to mitigate the specific MHRA Nitrofurantoin risk; no further software development is required.
Existing 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.
Linked response
Bedfordshire 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.1
Bedfordshire Hospitals NHS Foundation Trust
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
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.
Linked responses
National Institute for Health and Care Excellence
Royal College of Physicians
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Royal College of Physicians
Prescribing software alerts are determined by independent commercial providers, which choose the reference materials informing alert content.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Royal College of Physicians
Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
National Institute for Health and Care Excellence
BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
National Institute for Health and Care Excellence
NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.
Unable 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.
Linked response
Royal Cornwall Hospitals 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.1
Royal Cornwall Hospitals NHS Trust
Develop a sepsis alert within the new e-Care system to digitally flag when the sepsis six should be actioned.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Royal Cornwall Hospitals NHS Trust
The current NerveCentre system cannot support a digital sepsis alert, although an alert is planned for the replacement EPR system.
Unable 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.
Linked response
Surrey and Borders Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Surrey and Borders Partnership NHS Foundation Trust
The Trust considers its needs-based risk assessment and reduction process sufficient, so will not introduce a binary suicide-risk flag.
Existing 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
Linked responses
NHS England
Oracle Corporation UK Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Oracle Corporation UK Limited
Explore with Royal Surrey whether configuration or other changes could facilitate adherence to the clinical workflow, including broadening alert recipients.
Oracle Corporation UK Limited
Discuss with Royal Surrey establishing an alert-notifications committee to review existing alerts and identify new alerts for development.
NHS England
Engage Oracle Corporation UK Limited on the electronic prescribing alerting concerns raised in the Report.
NHS England
Consider incorporating a test script addressing the prescribing alerting issue into future ePRaSE iterations.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Oracle Corporation UK Limited
No evidence indicates a software defect; Millennium was working as designed and configured, including subsequent independent modifications.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Oracle Corporation UK Limited
Alerts are appropriately displayed within patient records and cannot substitute for clinicians following established clinical workflows and standards of care.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Oracle Corporation UK Limited
Login-based or external email alerts are considered unworkable because they risk alert fatigue, workflow disruption, lost acknowledgement monitoring and data-security breaches.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Oracle Corporation UK Limited
The client retains responsibility for deciding whether to adopt code or configuration enhancements, including their clinical and commercial implications.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.