Recurring concern
Unsafe medication administration
Pin
Get email alerts
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.
-
Concerns raised1
Delays in administering prescribed antibiotics
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The patient did not receive Teicoplanin during this admission; oral Doxycycline followed the subsequent knee washout.
Stated by Stockport NHS Foundation Trust
-
Position
Intravenous antibiotics were not indicated during the 48-hour period because the patient was clinically well and revision surgery was not planned.
Stated by Stockport NHS Foundation Trust
-
Concerns raised1
Failure to administer prescribed long-acting insulin as scheduled
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
-
Action
Establish a specialist Task and Finish Group to oversee the interim medication-chart solution.
Stated by Stockport NHS Foundation Trust -
Action
Review the medication-chart interface problem and develop an effective interim solution through the specialist Task and Finish Group.
Stated by Stockport NHS Foundation Trust
-
Concerns raised1
Failure to detect missed steroid doses
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Frequent administration of Omnipaque doses exceeding manufacturer guidelines
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.1
-
Action
Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.
Stated by University Hospitals Birmingham NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.
Stated by University Hospitals Birmingham NHS Foundation Trust
-
Concerns raised1
Failure to check prisoners' mouths during general medicine administration
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.
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
Observe and record medication swallowing, supplementing opioid-substitution administration with mouth checks and officer presence to address concealment concerns.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
There is no clinical requirement to check prisoners’ mouths when administering controlled or general medication.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to administer prescribed medication
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.8
-
Action
Refresh and embed the emergency-department medication protocol defining prescriber and nursing responsibilities for checking and administering prescriptions.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Adapt regular audit to check whether prescribed medication has been administered.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Strengthen handover between emergency-department and liaison teams to explicitly check prescribed, refused, outstanding and administered medications.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust
-
Action
Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Refresh and embed the emergency-department medication protocol requiring prescribers to notify nurses and nurses to check prescribed medicines.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Adapt regular audit to check whether prescribed medication has been administered.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Strengthen handover between emergency-department and mental-health liaison teams by explicitly checking medication status and recording findings in patient records.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Arrange honorary contracts enabling mental-health liaison prescribers to prescribe medication in the emergency department.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust
-
Concerns raised1
Failure of care home records to document conditions, symptoms and medication purposes
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.
-
Concerns raised1
Insufficient visibility of the heparin administration poster’s direction to seek haematology advice for underweight patients
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.
-
Concerns raised1
Lack of continuous stock records and verification for non-controlled ward 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.6
-
Action
Audit all clinical areas quarterly against safe and secure medicines-handling standards and discuss results with ward managers.
Stated by Bolton NHS Foundation Trust -
Action
Use the NHS Protect Medicines Security Ward/Department checklist to audit medicines security, collate divisional results and agree action plans.
Stated by Bolton NHS Foundation Trust -
Action
Operate one-stop dispensing to use patients’ own medicines, reduce stock-medicine use and record dispensing and stock-review information electronically.
Stated by Bolton NHS Foundation Trust
-
Action
Introduce a new Wardex recording pharmacists’ clinical reviews and medicine supply.
Stated by Bolton NHS Foundation Trust -
Action
Develop and implement a pharmacy policy endorsing Wardex entries, including medicine supply and quantity details.
Stated by Bolton NHS Foundation Trust -
Action
Present Safe and Secure Handling of Medicines audit results to the Medicines Safety Group for discussion and agreement of action plans.
Stated by Bolton NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing systems were considered sufficient to ensure ward medicines are stored securely and their stock can be verified.
Stated by Bolton NHS Foundation Trust
-
Concerns raised1
Lack of certainty whether Warfarin was being taken
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.
Data last updated 7 September 2026