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 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.
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
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
Stated by Department of Health and Social Care -
Action
Accelerate rollout of electronic prescribing for controlled drugs and medicines administration.
Stated by Department of Health and Social Care
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
Existing controlled-drug governance measures are considered sufficient to detect and minimise inappropriate use, although they cannot prevent every incident.
Stated by Department of Health and Social Care
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Position
Registered providers and managers are responsible for ensuring the proper and safe management of medicines in care homes.
Stated by Department of Health and Social Care
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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.
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
Implement an Electronic Prescribing System to prevent recurrence of fluid and potassium administration problems.
Stated by University Hospitals Sussex NHS Foundation Trust
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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.
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
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.
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
Stock ertapenem in the Emergency Department to prevent treatment delays.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Review Emergency Department trolleys and assess a trial trolley containing equipment, antibiotics and fluids for immediate sepsis care.
Stated by the Shrewsbury and Telford Hospital NHS Trust
-
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.
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 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.
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
Remove Lucozade, provide fresh fruit juice only after an accurate blood-glucose reading, and make diabetic interventions nurse-led.
Stated by Adbolton Hall 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
Diabetes care is considered adequately assessed and provided because relevant authorities were satisfied the home’s complex-needs admissions were safe.
Stated by Adbolton Hall Limited
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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.
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
Establish a working group with Emergency Department and Anaesthetics representation to address emergency intravenous drug administration.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Hold the working group’s scheduled meeting to examine resuscitation-area systems and processes.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Distribute the Intravenous Drugs Administration Policy to all qualified Emergency Department staff.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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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.
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 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.
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 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.
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
Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.
Stated by Care Quality Commission -
Action
Review the Trust’s controlled drug standard operating procedures through ongoing engagement.
Stated by Care Quality Commission
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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Position
The controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.
Stated by Care Quality Commission
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Position
The information currently held provides no evidence that the concerns reflect a systemic issue.
Stated by Care Quality Commission -
Position
No further regulatory action is considered necessary regarding this matter based on the information currently held.
Stated by Care Quality Commission
Data last updated 7 September 2026