Unreliable detection and monitoring of prescription errors
First to latest report 27 Jan 2014 — 17 Nov 2025
Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
11
What this concern includes
Includes dedicated controls for detecting, centrally recording, reviewing, monitoring or analysing prescription errors, including pharmacy reviews intended to identify errors and systems intended to detect trends or repeat errors across prescriptions.
What is not included
Excludes failures in investigating or learning from medication incidents after an error has already been identified where prescription-error detection or monitoring is not deficient.
Excludes generic clinical record-keeping, pharmacy staffing or medication-governance deficiencies unless they directly impair detection or monitoring of prescription errors.
Excludes prescribing, dispensing or administration errors themselves when no failure of the dedicated detection or monitoring control is identified.
Excludes monitoring of adverse medication outcomes or deaths where the asserted concern is not detection or monitoring of prescription errors.
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 England2
Department of Health and Social Care1
General Pharmaceutical Council1
Princess Alexandra Hospital1
Royal Pharmaceutical Society of Great Britain1
University Hospitals Plymouth NHS Trust1
Executive non-departmental public body2
Health and care professional regulator1
Healthcare site1
Health professional body1
Ministerial department1
NHS trust1
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
Essex
Concerns raised1
Failure to identify prescription errors and prior doses during controlled-drug checks
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
the Princess Alexandra Hospital 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.5
NHS England
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
NHS England
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
the Princess Alexandra Hospital NHS Trust
Introduce a patients’ own controlled drug book in the emergency department to record and account for patients’ controlled medicines.
the Princess Alexandra Hospital NHS Trust
Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.
the Princess Alexandra Hospital NHS Trust
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
NHS England
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Plymouth, Torbay and South Devon
Concerns raised1
Failure of Pharmacy reviews to identify prescription errors
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Plymouth 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
University Hospitals Plymouth NHS Trust
Deliver a pharmacist learning package covering therapeutic Clexane dosing, weight dependence and weight-loss-related dose changes.
York City
Concerns raised3
Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Absence of a central database of prescription errors
Lack of central monitoring and trend analysis of prescription errors
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
General Pharmaceutical Council
NHS England
Royal Pharmaceutical Society
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
NHS England
Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
NHS England
Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
NHS England
Negotiate the 2014/15 community pharmacy contract to specify minimum patient-safety incident reporting rates and highlight prescribing-error reporting.
NHS England
Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies.
General Pharmaceutical Council
Continue working with MHRA and NHS England to ensure pharmacy professionals use the National Reporting and Learning System.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Department of Health and Social Care
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
General Pharmaceutical Council
The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
NHS England
The National Reporting and Learning System is a central database for prescription errors, although community pharmacies underreport incidents.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Royal Pharmaceutical Society
The central prescription-error database is held by NHS England, which is expected to provide the relevant details.
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.