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
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.
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
Develop auditable electronic prescribing functionality that alerts doctors when pharmacists identify issues requiring review.
Stated by Medway NHS Foundation Trust
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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.
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.5
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Action
Employ a full-time read-coder to ensure correspondence is read-coded and necessary patient alerts are added.
Stated by Green Porch Medical Centre -
Action
Implement patient-record alerts that display relevant safety concerns at login until acknowledged.
Stated by Green Porch Medical Centre -
Action
Encourage clinicians to use Arden depression-review templates incorporating self-harm questions and automatic risk alerts.
Stated by Green Porch Medical Centre
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Action
Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.
Stated by Green Porch Medical Centre -
Action
Audit Docman for coding, document routing, follow-up completion and escalation of concerns, with audits every three months.
Stated by Green Porch Medical Centre
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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.
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
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.
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
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.
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
Review and update the Carenotes alert process, including agreed wording protocols linked to risk-assessment and suicide-prevention processes.
Stated by North London NHS Foundation Trust
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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.
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
NHSEI is responsible for systems oversight of controlled-drug management and use, including the alert system’s operation.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of the EMIS computer medical record to alert the medical centre to prior GP registration
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 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.
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
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.
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
The alert facility existed; failure to complete it was attributed to human factors rather than a system failure.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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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.
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.2
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Action
Implement escalating ECG technical alarms for “Arrhythmia Paused” and “Leads Off” states, including configurable escalation to a high-priority alarm.
Stated by GE Healthcare -
Action
Implement improved ventricular fibrillation detection using spectral analysis, faster alarm processing and data from all available ECG leads.
Stated by GE Healthcare
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 automated ECG arrhythmia detection algorithm operated within specifications and industry standards; signal conditions and rare rhythm prevented the alarm.
Stated by GE Healthcare
Data last updated 7 September 2026