Recurring concern
Unsafe medication prescribing
- Reports that mention this concern
- 121
- Times this concern has been raised
- 151
- Stated actions linked to this concern
- 246
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 121 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to limit medication supplies for patients with a history of prescribed-medication overdose
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Axminster Medical Practice
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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Axminster Medical Practice
The practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.
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Axminster Medical Practice
Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.
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Axminster Medical Practice
Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.
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Concerns raised1
Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring 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 staff training and Trust procedures to prevent prescribing and dispensing excessive paracetamol doses
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Bolton NHS Foundation Trust
Stated actions 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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Bolton NHS Foundation Trust
Review and revise paracetamol prescribing practice to require regular monitoring by the responsible clinical team.
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Bolton NHS Foundation Trust
Distribute the SBAR safety communication to medical staff, wards and services using paracetamol, including through staff newsletters and bulletins.
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Bolton NHS Foundation Trust
Amend the Medicines Management e-learning module to reflect the improved paracetamol prescribing process and circulate the message continually to clinical staff.
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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Bolton NHS Foundation Trust
All reasonably practicable steps have been taken to improve paracetamol prescribing and address the identified concerns.
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Concerns raised1
Failure of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Central East Integrated Care Board
Stated actions 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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NHS Central East Integrated Care Board
Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.
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NHS Central East Integrated Care Board
Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.
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NHS Central East Integrated Care Board
Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.
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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NHS Central East Integrated Care Board
Prescribing GPs are responsible for ensuring medication meets patients’ clinical needs, rather than relying on non-clinical care-home staff to identify errors.
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Concerns raised1
Failure of the repeat-prescribing system to prevent prescriptions of discontinued medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Eltham Palace Surgery
Stated actions 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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Eltham Palace Surgery
Carry out quarterly medication reviews through the CCG Prescribing Advisor.
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Eltham Palace Surgery
Carry out twice-yearly medication reviews using the practice computer records and electronic prescribing system.
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Concerns raised2
Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team
Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- MDU Services Limited
Stated actions 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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MDU Services Limited
Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.
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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MDU Services Limited
Prescribing medication after hospital mental-health referral was conventional within multidisciplinary care and was not inherently concerning.
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MDU Services Limited
The prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.
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MDU Services Limited
Using the existing medication was not shown to be unsafe: it had been tolerated previously and the subsequent psychiatrist did not change it.
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Concerns raised1
Inappropriate prescribing of gentamicin and aminophylline
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring 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
Prescribing medication in quantities sufficient for a fatal dose
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Lack of a system to ensure consideration of other prescribed medicines when prescribing tramadol
Failure of prescribers to apply the maximum tramadol dose for people over 75
Failure of prescribers to take patient size and frailty into account
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Prescribing and administering Bendroflumethiazide before blood test results were known
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Stockport NHS Foundation Trust
Stated actions 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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Stockport NHS Foundation Trust
Enable clinicians to electronically check all outpatient tests ordered in their name.
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Stockport NHS Foundation Trust
Include cross-disciplinary prescribing-alert capabilities in discussions of requirements with advanced electronic patient-record suppliers.
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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Department of Health and Social Care
No Summary Care Record flag for prescribing before test results is planned; the matter is left to doctors’ clinical and professional judgement.
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Stockport NHS Foundation Trust
A cross-disciplinary electronic alert for prescribing before test results are available cannot currently be created and is unlikely across most UK trusts.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026