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
Deficiencies in the administration of medications
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.7
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Action
Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.
Stated by Barchester Healthcare Limited -
Action
Provide further staff training on medicine management and record keeping.
Stated by Barchester Healthcare Limited -
Action
Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.
Stated by Barchester Healthcare Limited
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Action
Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.
Stated by Barchester Healthcare Limited -
Action
Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.
Stated by Barchester Healthcare Limited -
Action
Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.
Stated by Barchester Healthcare Limited -
Action
Update central medicine-management and end-of-life policies to reflect good practice.
Stated by Barchester Healthcare 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
The highest-end prescribed Midazolam dose was considered appropriate, based on the resident’s individual factors and agitation.
Stated by Barchester Healthcare Limited
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Concerns raised2
Failure of the drug administration chart to distinguish oral and intravenous paracetamol administration
Lack of patient-weight reference for intravenous paracetamol administration
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
Lack of clarity in recording whether Alteplase was followed by an infusion
Poor recording of medication delivery
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.
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Concerns raised1
Failure of clinicians visiting sick children at home to perform or confirm pH testing before medication administration
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.
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Concerns raised1
Delays in administering antibiotics after knee aspiration
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 discontinue prescribed medication when requested by hospital clinicians
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 discontinue medication when directed by hospital clinicians
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
Lack of a mechanism ensuring essential medications are prescribed, dispensed and administered
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 adjust paracetamol dosage for extremely low body weight
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.7
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Action
Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
Stated by the Rotherham NHS Foundation Trust -
Action
Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
Stated by the Rotherham NHS Foundation Trust -
Action
Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
Stated by the Rotherham NHS Foundation Trust
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Action
Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
Stated by the Rotherham NHS Foundation Trust -
Action
Provide and record required staff training on paracetamol dose reduction, including training during induction.
Stated by the Rotherham NHS Foundation Trust -
Action
Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
Stated by the Rotherham NHS Foundation Trust -
Action
Deliver a learning event discussing the specific case as part of the September safety programme.
Stated by the Rotherham 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
Body weight alone is not considered a marker of increased risk of oral paracetamol toxicity, although associated conditions may warrant dose reduction.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Insufficient control of medication administration at Alexandra Court Care Home
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