Recurring concern
Unsafe medication administration
- Reports that mention this concern
- 115
- Times this concern has been raised
- 147
- Stated actions linked to this concern
- 192
What this concern includes
Includes failures of controls dedicated to the end-to-end administration of prescribed medicines, including staff competence and supervision, administration accuracy and timing, monitoring, verification of ingestion, access and stock control, documentation, and follow-up of missed or incorrect doses.
What is not included
- Excludes prescribing-only, medication-selection or clinical-review deficiencies where the concern is not tied to administration.
- Excludes hazards involving counterfeit or unlawfully supplied medicines outside the administering organisation's medication-administration system.
- Excludes generic record-keeping, staffing or training deficiencies that are not specifically dedicated to safe medication administration.
- Excludes failures concerning unrelated information-sharing, assessment or care processes merely occurring in the same case.
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.
Reports and published responses 115 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to administer topical medication to the correct body site
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to administer prescribed PABRINEX
Failure to maintain complete and legible Medical Administration Records
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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
Unauthorised appropriation, trading and stockpiling of patient medication
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Care UK
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
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Care UK
Implement procedures to stop administering medication by sliding it under cell doors.
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Concerns raised1
Lack of clarity about propofol infusion duration, volume and dose
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring 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 administer prescribed medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Hc-One Limited
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
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Hc-One Limited
Provide additional training and competency assessment to the senior carer involved in the incident.
-
Concerns raised1
Lack of nursing staff training and confidence in administering prescribed oral morphine
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Prescribing and administering Bendroflumethiazide before blood test results were known
This report raised 11 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
- Stockport NHS Foundation 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.2
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Stockport NHS Foundation Trust
Enable clinicians to electronically check all outpatient tests ordered in their name.
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Stockport NHS Foundation Trust
Include cross-disciplinary prescribing-alert capabilities in discussions of requirements with advanced electronic patient-record suppliers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Department of Health and Social Care
No Summary Care Record flag for prescribing before test results is planned; the matter is left to doctors’ clinical and professional judgement.
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Stockport NHS Foundation Trust
A cross-disciplinary electronic alert for prescribing before test results are available cannot currently be created and is unlikely across most UK trusts.
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Concerns raised2
Insufficient training for administration of IV medications
Failure to document IV infusions stopped before full administration
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 monitor consumption of prescribed controlled drugs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 administer prescribed medication
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026