First reported 5 May 2013•Latest report 25 Jun 2026
Definition
What this concern includes
Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.
Not included
Excludes failures limited to medication administration after an otherwise appropriate prescription.
Excludes generic documentation, training or communication deficiencies unless they directly result in or are explicitly tied to an unsafe prescribing decision.
Excludes dispensing, supply or monitoring failures that do not concern whether the medication prescription itself was clinically appropriate.
Reports
121
Distinct published reports
Individual concerns
151
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
246
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.
Department of Health and Social Care20
NHS England16
Care Quality Commission7
NHS Greater Manchester Integrated Care Board7
General Medical Council6
National Institute for Health and Care Excellence4
Recipient name withheld4
Medicines and Healthcare products Regulatory Agency3
NHS Surrey and Sussex Integrated Care Board3
Royal College of General Practitioners3
Royal College of Physicians3
University Hospitals Birmingham NHS Foundation Trust3
Welsh Government3
BNF Publications2
Cwm Taf Morgannwg University Local Health Board2
NHS trust52
Healthcare site39
Ministerial department20
Executive non-departmental public body19
Integrated care board19
Type not available12
Health professional body8
Health and care professional regulator7
Health and social care service regulator7
Private limited company6
Local health board5
Independent healthcare provider4
Sub-organisation4
Clinical commissioning group3
Devolved government3
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.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to prescribe guideline-concordant antibiotics for patients previously colonised with ESBL
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 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 North
Concerns raised2
Failure to consider a lower methadone starting dose for patients with liver disease
Failure to obtain and verify relevant information about liver disease before prescribing
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.6
Action
Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Action
Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
Stated by Turning PointStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
Action
Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Action
Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
Action
Carry out a national audit of medical information available to opioid-substitute-treatment prescribers and documented interim considerations or actions.
Stated by Turning PointStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Action
Provide every organisational team with an NHS.net email address to enable secure information sharing with NHS bodies and employees.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
East London
Concerns raised1
Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury
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.4
Action
Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
Action
Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 December 2020.
Action
Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 December 2020.
Essex
Concerns raised1
Drug chart design failing to provide clear titration instructions for one-off IV morphine doses
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 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.1
Action
Roll out the approved Morphine Prescription sticker across inpatient prescription charts and audit its use.
Stated by East Suffolk and North Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 November 2020.
Black Country
Concerns raised3
Failure to avoid prescribing penicillin type antibiotics despite recorded adverse reactions
Failure to note recorded adverse reactions before prescribing
Failure to explain prescribing decisions despite recorded adverse reactions
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 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.6
Action
Review and update the allergy-recording policy to require consistent coding, visible allergy status, reaction severity and reaction descriptions, then provide it to staff.
Stated by Tettenhall Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Audit all electronically recorded allergic reactions and add available details distinguishing allergy or side effect, timing, severity and symptoms.
Stated by Tettenhall Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Action
Require clinicians to check documented allergies in the clinical record summary before prescribing.
Stated by Tettenhall Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Instruct clinicians not to prescribe medication carrying an electronic allergy alert.
Stated by Tettenhall Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Complete educational updates on prescription errors, prescribing, remote consultations, allergy and anaphylaxis, and pandemic-related change.
Stated by Tettenhall Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Remind clinicians to make clear and detailed patient-record notes.
Stated by Tettenhall Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Derby and Derbyshire
Concerns raised1
Failure to ensure clinicians know patients' full medical history before treating and prescribing
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 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
Enable all Derby and Derbyshire general practices to use GP2GP electronic record transfer.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
Action
Offer Ashbourne Medical Practice additional GP2GP and electronic record transfer training.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.
Action
Offer Ashbourne Medical Practice additional note summarisation training.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.
Manchester West
Concerns raised1
Failure of prescribing software dropdown controls to prevent selection of excessive twice-daily loading doses
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 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.
Inner North London
Concerns raised1
Failure to reconsider adrenaline auto injector dose after switching device
This report raised 20 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.11
Action
Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
Stated by NHS Enfield Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
Stated by NHS Enfield Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Require senior pharmacist approval of scriptswitch messages and GP Clinical Lead approval of newsletters before distribution.
Stated by NHS Enfield Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Establish an NCL primary care group to review local formulary and scriptswitch messaging and standardize messages across CCGs.
Stated by NHS Enfield Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Implement a post-incident review, produce a report, and submit it to the Quality and Safety Committee to oversee recommendations and implementation.
Stated by NHS Enfield Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Audit AAI patients’ prescribed doses and contact patients to confirm correct devices, usage knowledge and storage advice.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
Stated by the three G.Ps that were interested persons in the above matterStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Information about specific adrenaline auto-injector doses is a prescriber’s responsibility, not the call handler’s.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing BNF and BNFc advice sufficiently covers adrenaline auto-injector doses, quantities and training, so NICE will not duplicate that advice.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Failure to independently verify warfarin dosage before prescribing
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
Require Warfarin patients to present yellow books, record and verify INR results and doses, and confirm prescriptions before issuing them.
Stated by Brace Street Health CentreStated completedThe respondent said that this action was complete when they made their response on 30 October 2019.
Action
Implement a written procedure for prescribing Warfarin, checking INR results, and changing doses.
Stated by Brace Street Health CentreStated completedThe respondent said that this action was complete when they made their response on 30 October 2019.
Action
Assign the assistant practice manager to check Warfarin requests during the practice manager’s leave.
Stated by Brace Street Health CentreStated plannedThe respondent said that this action was planned when they made their response on 30 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Warfarin prescribing, monitoring and auditing systems are considered robust and sufficient to prevent further recurrences.
Stated by Brace Street Health CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Avon
Concerns raised1
Unsafe co-prescribing of clonazepam with methadone
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
Request marketing authorisation holders to update clonazepam and methadone product information, including warnings about respiratory depression and delayed methadone effects.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 November 2019.
Action
Remind healthcare professionals through a Drug Safety Update article about respiratory-depression risks when benzodiazepines and opioids are co-prescribed.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Action
Ensure development of a mental-health early-warning-score case study covering opioid use and over-sedation.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 10 November 2019.
Action
Develop prescribing guidance for mental health, endorsed by the Royal Pharmaceutical Society, with additional support, resources and learning materials.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinicians are responsible for prescribing decisions, including medication dosages and combinations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.
