First reported 27 Jan 2014•Latest report 17 Nov 2025
Definition
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.
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.
Reports
3
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
11
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.
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
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.
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.
Responses linked to these concerns
Each 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
Action
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Introduce a patients’ own controlled drug book in the emergency department to record and account for patients’ controlled medicines.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects 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.
Responses linked to these concerns
Each 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
Action
Deliver a pharmacist learning package covering therapeutic Clexane dosing, weight dependence and weight-loss-related dose changes.
Stated by University Hospitals Plymouth NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2016.
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.
Responses linked to these concerns
Each 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
Action
Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2014.
Action
Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.
Action
Negotiate the 2014/15 community pharmacy contract to specify minimum patient-safety incident reporting rates and highlight prescribing-error reporting.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2014.
Action
Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.
Action
Continue working with MHRA and NHS England to ensure pharmacy professionals use the National Reporting and Learning System.
Stated by General Pharmaceutical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
Stated by General Pharmaceutical CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The National Reporting and Learning System is a central database for prescription errors, although community pharmacies underreport incidents.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The central prescription-error database is held by NHS England, which is expected to provide the relevant details.
Stated by Royal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
