First reported 9 May 2014•Latest report 21 May 2024
Definition
What this concern includes
Includes failures to individualise medication doses using relevant patient-specific factors such as body weight, comorbidities, organ function and other clinically material characteristics, including morphine dosing and dosing based on an inaccurately determined patient weight.
Not included
Excludes generic medication-prescribing, dispensing or administration failures where patient-specific dose individualisation is not the deficient control.
Excludes failures to verify or communicate an already correctly individualised dose when the dose-selection process itself was adequate.
Excludes general medication monitoring, reconciliation or review failures that do not concern determining an appropriate patient-specific dose.
Excludes weight measurement failures where the weight is not used or intended for medication dose determination.
Reports
7
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
10
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.
Barking, Havering and Redbridge University Hospitals NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
East Lancashire Hospitals NHS Trust1
National Institute for Health and Care Excellence1
Queen's Hospital, Romford1
Southampton General Hospital1
the Rotherham NHS Foundation Trust1
Tredegar Practice1
University Hospital Southampton NHS Foundation Trust1
NHS trust5
Healthcare site3
Executive non-departmental public body1
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.
Inner North London
Concerns raised1
Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Lack of careful consideration of contrast medium dose
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 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.2
Action
Specify contrast dosing at 1 ml/kg up to a 100 ml maximum.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Provide medical scales for all scanners to support the specified contrast dosing.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2020.
Portsmouth and South East Hampshire
Concerns raised2
Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing
Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Eastern)
Concerns raised1
Failure to adjust paracetamol dosage for extremely low body weight
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.7
Action
Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Provide and record required staff training on paracetamol dose reduction, including training during induction.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Action
Deliver a learning event discussing the specific case as part of the September safety programme.
Stated by the Rotherham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 April 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Body weight alone is not considered a marker of increased risk of oral paracetamol toxicity, although associated conditions may warrant dose reduction.
Stated by the Rotherham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Blackburn, Hyndburn and Ribble Valley
Concerns raised1
Failure of prescribers to apply the maximum tramadol dose for people over 75
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to individualise maximum morphine doses to body weight, comorbidities and other relevant factors
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 concerns
Each 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.2
Position
This case does not prompt a review of the maximum permitted morphine dose because analgesic requirements vary and tolerance develops with chronic administration.
Stated by Medicines and Healthcare products Regulatory AgencyNo action considered necessaryThe respondent said that no further action was needed.
Position
Maximum morphine dosing need not be adjusted for body weight or comorbidities because prescribing information already advises dose reduction in specified circumstances.
Stated by Medicines and Healthcare products Regulatory AgencyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Blackpool and the Fylde
Concerns raised1
Failure to accurately determine patient weight for medication dosage
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
Perform Mid Upper Arm Circumference calculations using MUST when patients cannot be weighed, to assist in establishing accurate weight.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Exact patient weight is not required for dalteparin dosage; verbal weight assessment is acceptable when physical weighing is not possible.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures to individualise medication doses using relevant patient-specific factors such as body weight, comorbidities, organ function and other clinically material characteristics, including morphine dosing and dosing based on an inaccurately determined patient weight.
