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
Unmeasured dosing from the medication bottle
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.1
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Action
Request MHRA approval to add an explicit warning against drinking Oramorph directly from the bottle and describe overdose risks in the patient information leaflet.
Stated by Boehringer Ingelheim Limited
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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Position
Existing dosing instructions and approved labelling were considered sufficiently clear despite lacking an explicit warning against drinking directly from the bottle.
Stated by Boehringer Ingelheim Limited
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Concerns raised1
Medication administration by agency nurses unfamiliar with the unit
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.3
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Action
Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
Stated by Hc-One Limited -
Action
Complete and distribute a strengthened agency-staff orientation booklet across the company.
Stated by Hc-One Limited -
Action
Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
Stated by Hc-One Limited
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Concerns raised1
Failure to administer the correct dose of insulin
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.1
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Action
Review the pharmacy drug-chart auditing process and disseminate serious-incident learning through the monthly Medicines Safety News editorial.
Stated by Maidstone and Tunbridge Wells NHS Trust
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Concerns raised1
Failure of paramedics to recognise the dangers of administering Rivaroxaban
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.1
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Action
Publish Clinical Notice 18 to clinicians, covering Novel Oral Anticoagulants including Rivaroxaban and providing advice on their use.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Failure to check administration of Oramorph and account for symptom masking
This report raised 11 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.
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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Position
There is no pharmaceutical requirement for Oramorph to be double-checked.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure to prevent prescribing and administration of a documented allergenic medication
This report raised 5 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
Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Undertake medicines reconciliation for every patient as soon as possible after admission.
Stated by University Hospitals Sussex NHS Foundation Trust
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Action
Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
Stated by University Hospitals Sussex NHS Foundation Trust
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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Position
Purchase of the EPMA package cannot proceed until NHS England decides its funding allocation.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to administer prescribed prophylactic anticoagulation
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 raised2
Failure to administer prescribed steroids
Lack of a policy for steroid administration and use with multiple comorbidities
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 raised2
Administration of anticoagulation medication following a head injury
Failure to restrict anticoagulation medication advice or administration involving ambulance technicians
Responses linked to these concernsEach 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
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Position
Advising on Apixaban and other medications beyond six authorised medications falls outside an EMT’s scope of practice.
Stated by North West Ambulance Service NHS Trust
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Position
The nursing-home nurse, rather than an EMT, was responsible for deciding which medication should be administered and when.
Stated by North West Ambulance Service NHS Trust
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Concerns raised3
Unclear governance for non-administration of prescribed medication
Lack of audit of on-time administration of critical medication
Lack of follow-up and recording of prescribed medication non-attendance
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 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.
Data last updated 7 September 2026