First reported 19 Sep 2013•Latest report 19 Mar 2026
Definition
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
Distinct published reports
Individual concerns
147
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
192
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.
Care Quality Commission7
Stockport NHS Foundation Trust7
Department of Health and Social Care6
Ministry of Justice4
NHS England4
Tameside and Glossop Integrated Care NHS Foundation Trust4
HM Prison and Probation Service3
Nursing and Midwifery Council3
University Hospitals Sussex NHS Foundation Trust3
Barking, Havering and Redbridge University Hospitals NHS Trust2
Care UK2
Hc-One Limited2
Leeds Prison2
Leeds Teaching Hospitals NHS Trust2
Manchester University NHS Foundation Trust2
NHS trust66
Healthcare site22
Ministerial department10
Health and social care service regulator7
Multi-service care provider7
Prison or young offender institution7
Private limited company7
Residential care home6
Executive non-departmental public body5
Health and care professional regulator4
Type not available4
Executive agency3
Health professional body3
Coronial office2
Domiciliary care provider2
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.
East London
Concerns raised1
Omissions of prescribed daily low molecular weight heparin injections
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.
West London
Concerns raised1
Failure to control staff access to residents' 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 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
Develop a robust action plan covering controlled-drug training and ongoing medication monitoring for auditors and managers.
Stated by Care OutlookStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.
Inner South London
Concerns raised1
Failure to confirm and record timely administration of Amikacin
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.
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
Remind clinical staff to administer prescribed critical medications within one hour and reinforce this through ward and team meetings.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust states antibiotics were administered within an hour, disputing that Amikacin administration timing was unconfirmed or late.
Stated by Lewisham and Greenwich NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cornwall and Isles of Scilly
Concerns raised2
Delays or omissions in the administration of prescribed Parkinson’s medication
Delays in the administration of 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 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.
Blackpool and the Fylde
Concerns raised2
Failure to record the actual medication dose given
Failure of the Once-only and Pre-medication Chart to provide for recording the actual dose when a dose range is prescribed
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 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
Require variable medication doses to be recorded in the PRN chart and monitor compliance through the Emergency Department pharmacist.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Variable medication doses are recorded in the PRN section rather than the once-only chart, reflecting standard hospital practice.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of controlled drug checks to identify unaccounted drugs
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised3
Failure to establish why prescribed medication was not given as ordered
Delays in giving prescribed Beriplex
Failure to check administration of prescribed medication after an extension of bleeding
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised2
Incomplete medication administration charts
Failure to check antibiotic administration
This report raised 9 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.
Manchester West
Concerns raised2
Failure to check medication packaging and labelling against the prescription chart before administration
Insufficient training, auditing, supervision and monitoring of nursing and pharmacy staff on medication checking controls
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.10
Action
Implement closed-loop medication administration using electronic barcode scanning of patients and medications.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Update accuracy-checking procedures to require a second check for all intravenous fluids.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Ensure nursing staff recognise different Polyfusor products and check all medication details in full.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Arrange staff feedback sessions on improvements to clinical checking, dispensing and accuracy-checking processes.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Introduce formal revalidation for staff involved in dispensing errors.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Introduce a recurring accuracy-checking log for all accuracy checkers to monitor competence.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Review the accuracy-checking test to cover a wider range of medications.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Monitor completion of medicines-safety training by nursing staff on Ward H2.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 October 2019.
Action
Ensure Ward H2 nursing staff comply with mandatory medicines-safety training and monitor their compliance.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Conduct weekly senior-nurse walkabouts on Ward H2, observing nursing medication and fluid dispensing-checking procedures.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Cornwall and Isles of Scilly
Concerns raised1
Failure of the system for monitoring compliance with prescribed medication
This report raised 7 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
Review the medication procedure and add immediate post-medication room checks to the Medication Policy.
Stated by PENTRE LODGE CARE HOME LIMITEDStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
Action
Introduce individual medication-room administration behind a closed door and conduct rigorous face-to-face medication training for all staff.
Stated by PENTRE LODGE CARE HOME LIMITEDStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing room checks were considered to require little improvement beyond immediate checks when medication is found.
Stated by PENTRE LODGE CARE HOME LIMITEDExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
