Recurring concern
Unreliable clinical safety-alert systems
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Request correctionFirst reported 12 Oct 2013•Latest report 1 Apr 2026
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
- Individual concerns
- 56
- Date range
- 2013–2026
- Stated actions
- 66
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
Failure to record acknowledged amitriptyline risks in an accessible way for all practitioners
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.
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
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Action
Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Stated by Tredegar Practice
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Concerns raised1
Failure of NSAID prescribing software to automatically generate specific warning flags for prescribing considerations and risk factors
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.1
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Action
Work with all practices to highlight the importance of using OptimiseRx and Eclipse prescribing safety tools.
Stated by NHS Lincolnshire Integrated Care Board
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Concerns raised1
Lack of a system requiring radiologists to alert clinicians to inconsistencies before finalising their reports
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.1
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Action
Implement a discrepancy-management procedure requiring senior radiographer checks, clinician notification when unresolved, and documentation of communications or corrections in reports.
Stated by Bristol NHS Foundation Trust
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Concerns raised1
Failure to record adverse medication markers on computerised medical records
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.1
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Action
Maintain an electronic medication alert identifying contraindicated or potentially misused medicines and interactions with methadone.
Stated by The Croft Shifa Health Centre
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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Position
The existing computerised medication alert is considered sufficient to identify potentially contraindicated or misused medicines when prescribing.
Stated by The Croft Shifa Health Centre
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Concerns raised2
Failure to enter an alert in the digital system when clinical notes have been handwritten
Lack of an EPMA alert requiring review of ongoing suspension of prescribed 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 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.1
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Action
Progress the contracted integrated electronic patient record programme toward operational use from Spring 2025.
Stated by Royal Cornwall Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Because specialties must record inpatient entries in paper notes, no electronic alert is considered necessary for handwritten clinical entries.
Stated by Royal Cornwall Hospitals NHS Trust
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Position
The prescribing system cannot create suspension alerts, and separate alerts are considered potentially counterproductive because of prescriber alert fatigue.
Stated by Royal Cornwall Hospitals NHS Trust -
Position
Existing visual prompts on suspended medicines and ward-round drug-chart reviews are considered sufficient to support medication review without a separate alert.
Stated by Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure to alert requesting teams to suspicious radiological findings treated as expected findings
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.6
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Action
Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Provide an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
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.1
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Action
Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
Stated by Barts Health NHS Trust
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Concerns raised1
Lack of a national risk-flagging system for previous self-harm attendances
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 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
Lack of automatic GP-record alerts for smear-test non-responders
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
Undertake an internal review of the concerns raised in the report.
Stated by EMIS Group -
Action
Provide an automatic home-screen alert when a patient is due for a cervical smear, regardless of prior attendance.
Stated by The Phoenix Partnership (Leeds) Ltd -
Action
Provide a report listing patients due for cervical screening so practices can issue letters, reminders or SMS messages.
Stated by The Phoenix Partnership (Leeds) Ltd
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Existing System alerts and functionality already meet required specifications and the recommendation for automatic cervical screening alerts.
Stated by EMIS Group
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Position
CQC lacks statutory powers over clinical system providers and therefore cannot directly require improvements in this area.
Stated by Department of Health and Social Care -
Position
GP IT systems automatically display overdue cervical-screening alerts, including for non-responders, so the concern that records lack an alert is incorrect.
Stated by NHS England -
Position
The system cannot alert GPs to non-response because the National Screening Service does not provide that information directly to electronic patient records.
Stated by The Phoenix Partnership (Leeds) Ltd
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Concerns raised1
Lack of an integrated cross-pharmacy prescription alert system
This report raised 9 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.1
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Position
NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.
Stated by Department of Health and Social Care
Data last updated 7 September 2026