First reported 27 Jan 2014•Latest report 28 Nov 2024
Definition
What this concern includes
Includes failures of checking, assurance or operational controls dedicated to detecting and correcting errors during medication dispensing or dispatch, including errors identified after prescribing where the dispensing process is implicated.
Not included
Excludes prescribing errors with no dispensing or dispatch-control component.
Excludes medication administration errors unless the failure concerns an upstream dispensing or dispatch control.
Excludes generic incident-reporting, documentation or learning failures not explicitly tied to detecting or correcting medication dispensing or dispatch errors.
Excludes ambulance or other emergency-service dispatch concerns.
Reports
5
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
12
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.
Medicines and Healthcare products Regulatory Agency2
Clare House Surgery1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
General Pharmaceutical Council1
NHS England1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Nursing and Midwifery Council1
Pharmacy2U Limited1
Royal Pharmaceutical Society1
Royal Pharmaceutical Society of Great Britain1
Health and care professional regulator2
Health professional body2
Medicines and medical devices regulator2
Executive non-departmental public body1
Healthcare site1
Integrated care board1
Local health board1
Ministerial department1
NHS trust1
Private limited company1
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.
Devon, Plymouth and Torbay
Concerns raised1
Medication dispatch failing to allow mistakes to be noticed and remedied
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 concerns
Each 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
Monitor rejected electronic cancellation notifications daily and act on them when required.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Eliminate non-auditable messaging systems for clinical information in prescription management.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The benefits of efficient, timely medicine supply outweigh the risks because prescribers should complete clinical appropriateness assessments before issuing prescriptions.
Stated by Royal Pharmaceutical SocietyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing dispensing processes and required reasonable promptness are considered sufficient; planned delays to allow post-prescribing checks would be unsafe and disproportionate.
Stated by Pharmacy2UExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The practice cannot easily cancel prescriptions after pharmacy download because cancellation routes and pharmacy communications are not sufficiently accessible.
Stated by Partners of Amicus Health GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Changing online pharmacies’ rapid prescription dispatch and automatic drawdown is outside the practice’s scope.
Stated by Partners of Amicus Health GroupOutside remitThe respondent said that this matter was outside its role or authority.
Position
Online pharmacies and relevant regulatory bodies are asked to review and improve prescription cancellation and communication processes.
Stated by Partners of Amicus Health GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Wales Central
Concerns raised1
Failure to detect prescribing and dispensing errors at discharge
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of pharmacy checks to prevent inadvertent dispensing to vulnerable adults
Responses linked to these concerns
Each 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
Action
Issue best-practice guidance recommending differentiated medicine packaging to reduce selection errors.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
Action
Publish a Drug Safety Update article reminding healthcare professionals to remain vigilant for medicine-name confusion errors.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
Action
Review atenolol and amitriptyline packaging for potential improvements that could reduce future dispensing errors.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 14 June 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Community pharmacy services fall outside the respondent’s responsibility.
Stated by NHS Greater Manchester Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS England is responsible for community pharmacy services.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The key safety issue is pharmacy dispensing, not carers’ clinical qualifications or medication-administration responsibilities.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts
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 concerns
Each 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.4
Action
Implement closed-loop dispensing by linking electronic prescribing, pharmacy dispensing and robotic systems.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Implement closed-loop medication administration using electronic barcode scanning of patients and medications.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Update accuracy-checking procedures to require a second check for all intravenous fluids.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
Action
Ensure nursing staff recognise different Polyfusor products and check all medication details in full.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 October 2019.
York City
Concerns raised3
Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Failure of colleague checking to prevent dispensing medication errors
Lack of mandatory read-back procedures for dispensing details
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 concerns
Each 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
Action
Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2014.
Action
Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.
Action
Highlight existing dispensing-error guidance, including involving two people where possible, in the next Regulate+ newsletter.
Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
Stated by General Pharmaceutical CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Pin
Get email alerts
Request correction
Includes failures of checking, assurance or operational controls dedicated to detecting and correcting errors during medication dispensing or dispatch, including errors identified after prescribing where the dispensing process is implicated.
