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 raised2
Failure to prevent unauthorised access and repeated administration of Oramorph
Significant impact from excess administration of opioids at any prescribed strength
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
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
-
Department of Health and Social Care
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
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Department of Health and Social Care
Accelerate rollout of electronic prescribing for controlled drugs and medicines administration.
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
Existing controlled-drug governance measures are considered sufficient to detect and minimise inappropriate use, although they cannot prevent every incident.
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Department of Health and Social Care
Registered providers and managers are responsible for ensuring the proper and safe management of medicines in care homes.
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Concerns raised2
Failure to administer prescribed potassium
Failure to provide prescribed Cyclazine
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Sussex 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.1
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University Hospitals Sussex NHS Foundation Trust
Implement an Electronic Prescribing System to prevent recurrence of fluid and potassium administration problems.
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Concerns raised1
Failure to administer antibiotics at an earlier stage
This report raised 3 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
Unavailability of prescribed drugs in the A&E department
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- the Shrewsbury and Telford 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.2
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the Shrewsbury and Telford Hospital NHS Trust
Stock ertapenem in the Emergency Department to prevent treatment delays.
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the Shrewsbury and Telford Hospital NHS Trust
Review Emergency Department trolleys and assess a trial trolley containing equipment, antibiotics and fluids for immediate sepsis care.
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Concerns raised1
Failure to administer anticoagulation medication correctly
This report raised 3 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 Lucozade safely when blood glucose levels are unavailable or critically high
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Adbolton Hall 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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Adbolton Hall Limited
Remove Lucozade, provide fresh fruit juice only after an accurate blood-glucose reading, and make diabetic interventions nurse-led.
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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Adbolton Hall Limited
Diabetes care is considered adequately assessed and provided because relevant authorities were satisfied the home’s complex-needs admissions were safe.
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Concerns raised1
Lack of checking of verbally prescribed drugs before administration
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals 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.3
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Establish a working group with Emergency Department and Anaesthetics representation to address emergency intravenous drug administration.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Hold the working group’s scheduled meeting to examine resuscitation-area systems and processes.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Distribute the Intravenous Drugs Administration Policy to all qualified Emergency Department staff.
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Concerns raised1
Failure to ensure availability and administration of prescribed medication
This report raised 12 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 use insulin-specific syringes when drawing up and administering insulin
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 raised1
Failure of the system for administration of controlled drugs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Care Quality Commission
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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Care Quality Commission
Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.
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Care Quality Commission
Review the Trust’s controlled drug standard operating procedures through ongoing engagement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Care Quality Commission
The controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.
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Care Quality Commission
The information currently held provides no evidence that the concerns reflect a systemic issue.
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Care Quality Commission
No further regulatory action is considered necessary regarding this matter based on the information currently held.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026