Recurring concern
Unsafe medication administration
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Request correctionFirst reported 19 Sep 2013•Latest report 19 Mar 2026
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.
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.
- Reports
- 115
- Individual concerns
- 147
- Date range
- 2013–2026
- Stated actions
- 192
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to ensure administration and escalation of missed antibiotic doses
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Audit omitted medication doses through pharmacy, ward quality-assurance and accreditation processes, reporting results and sharing learning for improvement.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Issue a staff poster explaining how to prevent medication omissions and obtain unavailable medicines.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Redesign the medication kardex to highlight time-critical medicines and streamline ward medication-ordering and emergency supply arrangements.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Provide each ward with an allocated pharmacist and pharmacy technician to review treatment sheets daily and support timely medication ordering.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Provide medication-omission induction and refresher training, with medication-management assessment for nurses new to the Trust.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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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Position
The concerns fall under the Trust’s remit rather than NHS England’s functions.
Stated by NHS England
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Position
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Stated by NHS England
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Concerns raised1
Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
Responses linked to these concernsEach 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
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Action
Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to administer the prescribed steroid dosage accurately
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 concernsEach statement is shown once, even when linked to more than one 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 supervise syringe medication
Responses linked to these concernsEach 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
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Action
Conduct weekly observations of medicine rounds.
Stated by Four Seasons Health Care Group -
Action
Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.
Stated by Four Seasons Health Care Group
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Concerns raised1
Failure to administer as-needed morphine only when required
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Provide person-centred protocols and care-plan instructions for PRN medicines, including pain assessment for residents unable to verbalise pain.
Stated by Runwood Homes PLC -
Action
Deliver additional medication training to senior care staff to develop their medication-administration skills.
Stated by Runwood Homes PLC
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Concerns raised1
Delays in administering prescribed antibiotics
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 concernsEach 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
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Action
Develop and deliver an SBAR handover training programme for all neonatal intensive care nursing and medical staff.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Debrief staff involved in the delayed antibiotic communication.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to assess intracranial damage before prescribing and administering enoxaparin
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 concernsEach statement is shown once, even when linked to more than one 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 monitor the frequency of PRN medication administration
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 concernsEach 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
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Action
Update medication-monitoring practice and jointly monitor its implementation with the chief pharmacist.
Stated by North East London NHS Foundation Trust -
Action
Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.
Stated by High Street Surgery
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Concerns raised1
Failure to secure and control prisoners’ prescribed medication
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 concernsEach 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.6
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Action
Issue staff guidance on detecting, recording and reporting prescribed-medication trading.
Stated by HM Prison and Probation Service -
Action
Reissue medication-trading guidance annually to maintain staff awareness and inform new staff.
Stated by HM Prison and Probation Service -
Action
Monitor and collate medication-trading intelligence for consideration at weekly staff security briefings.
Stated by HM Prison and Probation Service
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Action
Apply detailed security risk assessments to prisoners working in the recycling department.
Stated by HM Prison and Probation Service -
Action
Install amnesty bins on prison wings for correct disposal of medications.
Stated by HM Prison and Probation Service -
Action
Conduct monthly random medication checks covering 10% of the prison population and address discrepancies through medication reviews.
Stated by HM Prison and Probation Service
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Concerns raised1
Lack of appropriate limits on the administration of certain drugs
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 concernsEach 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.4
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Action
Implement dose-error-reduction infusion pumps and medication libraries across all clinical areas, with specified concentrations and dosing safety limits.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Educate staff to use medication libraries and not bypass safety limits except in exceptional circumstances.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Investigate developing limits for entries in the Cerner infusion chart for selected narrow-dose-safety-profile drugs.
Stated by Oxford University Hospitals NHS Foundation Trust
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Action
Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.
Stated by Oxford University Hospitals NHS Foundation Trust
Data last updated 7 September 2026