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 withhold blood-thinning medication while awaiting CT results for brain 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 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 targeted education and training for emergency and acute care staff on anticoagulation risks, clinical vigilance and deferring treatment pending imaging.
Stated by Stockport NHS Foundation Trust -
Action
Complete an internal review of anticoagulation practice while intracranial pathology remains possible.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure to supervise medication taking as specifically instructed
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 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
Review the CRHTT medications management process, standard operating procedure and staff orientation resources to clarify responsibilities and decision-making.
Stated by The Trust -
Action
Develop a medications-management flowchart and assessment pro-forma to support administration-route decisions and efficacy assessment.
Stated by The Trust -
Action
Adopt the new medications-management flowchart and assessment pro-forma for use by the CRHTT.
Stated by The Trust
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Concerns raised1
Absence of medication-administration alerts for adults at risk of unintentional paracetamol overdose
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.1
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Action
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Stated by Bedfordshire Hospitals NHS Foundation Trust
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Concerns raised1
Failure to administer the first antibiotic dose in the emergency department
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.3
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Action
Provide mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.
Stated by Royal Free London NHS Foundation Trust -
Action
Progress plans for dedicated emergency-department pharmacy provision through the business-case approval process.
Stated by Royal Free London NHS Foundation Trust -
Action
Ensure sufficient adult TTA medication stock and assign medication-stock responsibilities in job planning.
Stated by Royal Free London 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
Earlier antibiotics were unlikely to have altered Billie’s outcome because the infection was likely viral, although earlier treatment may benefit similar patients.
Stated by Royal Free London NHS Foundation Trust
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Position
No national guidance or clear rationale supports requiring clinicians to administer the first antibiotic dose absent suspected allergy.
Stated by Royal College of Emergency Medicine
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Concerns raised1
Failure to promptly administer prescribed medications
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.3
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Action
Update the medication policy to require medical advice when emergency medication is unavailable for three hours.
Stated by WCG Abbey Ltd -
Action
Implement an electronic medication system providing daily management oversight of stock levels, missed medicines and other medication issues.
Stated by WCG Abbey Ltd -
Action
Move all residents to the same GP surgery and pharmacy to improve communication and medication processes.
Stated by WCG Abbey Ltd
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Concerns raised2
Failure of insulin-administration training to reach all nurses
Failure to administer insulin before meals
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 prevent administration of morphine to patients with recorded opioid allergies
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.1
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Action
Share learning from the opioid analgesia incident with Emergency Department colleagues to inform future practice.
Stated by Mid and South Essex 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
Opioid analgesia was within acceptable clinical decision-making, so further review or safeguarding was not considered necessary.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Lack of a protocol for medication oversight after client falls
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 of hospital systems to review and safeguard medication prescribing and 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.
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
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Stated by Inmind Healthcare
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Concerns raised2
Variation in local anaesthetic administration practices
Unclear responsibility for administering the local anaesthetic
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026