Recurring concern

Failure to reliably detect discrepancies between prescribed and administered medication

First to latest report 25 Jun 2015 — 25 Nov 2021

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 9

What this concern includes

Includes failures of controls intended to compare, reconcile, flag or escalate discrepancies between prescribed medication and medication recorded as administered, including discrepancies during discharge or care transitions and failures to detect differences between prescription and administration records.

What is not included

Excludes general medication reconciliation, prescribing, administration or discharge-medication failures where no discrepancy-detection or checking failure is identified.
Excludes failures to act on a discrepancy after it has been reliably detected when the detection process itself was adequate.
Excludes medication dosage, quantity, supply or adherence concerns that do not involve detecting a discrepancy between prescribed and administered medication.
Excludes generic record-keeping, staffing or communication deficiencies unless they directly impair medication-discrepancy detection.

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

Reports about this concern sent to each recipient.

Good Hope Hospital1

John Radcliffe Hospital1

Oxford University Hospitals NHS Foundation Trust1

University Hospitals Birmingham NHS Foundation Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

25 Nov2021
Berkshire
Concerns raised1
1. Lack of a system for flagging discrepancies between drug prescription and administration
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Oxford University Hospitals NHS Foundation Trust
Stated actions 2
1. Oxford University Hospitals NHS Foundation Trust
  Include automated drug prescription-to-administration specifications in the future single clinical system procurement.
2. Oxford University Hospitals NHS Foundation Trust
  Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.
Respondent positions 1
1. Oxford University Hospitals NHS Foundation Trust
  Matching prescriptions to constantly adjusted infusion rates is impractical in critical care because bedside rates frequently change.
  Unable to act
AI-generated summary

Saif Mubeen Hussain · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Saif Mubeen Hussain died at John Radcliffe Hospital on 10 June 2021 after being admitted following an incident in Bracknell, Berkshire, on 3 June 2021; the recorded cause of death was polytrauma. During his transfer between units, he was administered a Heparin infusion at almost eight times the prescribed rate. The report identified concerns about unfamiliarity with anticoagulants, inadequate double-checking, the Guardrails system being switched off, differences between prescription and administration rates not being flagged, and the use of separate hospital computer systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a system for flagging discrepancies between drug prescription and administration
Wider context from the report
“4. Adopting a system of flagging up where prescription and administration of drugs is different. ”
Source location
Saif Mubeen Hussain · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Include automated drug prescription-to-administration specifications in the future single clinical system procurement.

Verbatim wording from the response
“The Trust accepts the need to strengthen the decision support tools within the current clinical systems. We are looking to further improve the embedded system rules regarding drug prescription and administration.”

Source location
2021-0399-Response-from-Oxford-University-Hospitals_Published
Page 2 · response
Published 29 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce new infusion pumps across all sites with bi-directional communication capability between pumps and the Cerner clinical system.

Verbatim wording from the response
“In addition, the Trust is in the process of introducing new infusion pumps across all sites. One of the requirements for the procurement of these pumps was that they should allow bi-directional communication between the pumps and the Cerner clinical system. This would allow auto-programming of the pump from the electronic prescription and would automatically update the hourly infusion rate recorded in the iView infusion section of the drug chart. If the bi-directional communication capability of these pumps were to be used, this would significantly reduce the volume of manually entered data and remove the risk of transcription errors by bedside nurses when programming pumps or recording infusion rates.”

Source location
2021-0399-Response-from-Oxford-University-Hospitals_Published
Page 3 · response
Published 29 November 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Matching prescriptions to constantly adjusted infusion rates is impractical in critical care because bedside rates frequently change.

Verbatim wording from the response
“4. Adopting a system of flagging up where prescription and administration of drugs is different.”

Source location
2021-0399-Response-from-Oxford-University-Hospitals_Published
Page 2 · response
Published 29 November 2021
Open published response
25 Jun2015
Birmingham and Solihull
Concerns raised2
1. Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation
2. Lack of a protocol for easily checking medication discrepancies
Linked response

University Hospitals Birmingham NHS Foundation Trust
Stated actions 7
1. University Hospitals Birmingham NHS Foundation Trust
  Amend the nursing discharge checklist to remind staff to check the PEPMAC.
2. University Hospitals Birmingham NHS Foundation Trust
  Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.
3. University Hospitals Birmingham NHS Foundation Trust
  Obtain governance approval and pilot the revised yellow-card documentation within palliative care.
1. University Hospitals Birmingham NHS Foundation Trust
  Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.
2. University Hospitals Birmingham NHS Foundation Trust
  Check available MAC charts and TTOs for medication discrepancies.
3. University Hospitals Birmingham NHS Foundation Trust
  Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.
4. University Hospitals Birmingham NHS Foundation Trust
  Review existing pharmacy SOPs to ensure they are robust and fit for purpose.
AI-generated summary

Lottie Reid · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lottie Reid, aged 95, was readmitted to hospital with haematemesis and melaena and died on 29 January 2015. The inquest concluded that she died from bleeding duodenal ulcers on a background of other significant natural disease, with her death probably accelerated by bleeding exacerbated by anticoagulant therapy. Concerns were raised that the medication administration chart at the intermediate care centre did not mirror the hospital discharge documentation and that there was no clear protocol for checking discrepancies, particularly at weekends.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation
Wider context from the report
“(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription. (2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends ”
Source location
Lottie Reid · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a protocol for easily checking medication discrepancies
Wider context from the report
“(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription. (2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends ”
Source location
Lottie Reid · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the nursing discharge checklist to remind staff to check the PEPMAC.

Verbatim wording from the response
“In order that the risk of future events can be reduced the following steps have been taken by the Trust:”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.

Verbatim wording from the response
“In addition to strengthening the processes as described above, we consider that this case is an opportunity to improve the discharge process and the documentation in particular:”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Obtain governance approval and pilot the revised yellow-card documentation within palliative care.

Verbatim wording from the response
“This process will reduce the risk of inconsistency in the discharge documents for the patient, as there will only be one document that the clinicians will refer to on discharge. The template will be standardised to ensure it contains the optimal information for safe prescribing and administration.”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.

Verbatim wording from the response
“Once the new documentation has been approved through our governance processes, it will be piloted within palliative care. Subject to feedback from the community staff, a final decision as to the appropriateness of implementing this process for patients being discharged into an intermediate care facility will be made. It is likely that this decision will be made in the next six months, and will be based on clarity of the prescribing and a review of any reported incidents.”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Check available MAC charts and TTOs for medication discrepancies.

Verbatim wording from the response
“6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.

Verbatim wording from the response
“6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review existing pharmacy SOPs to ensure they are robust and fit for purpose.

Verbatim wording from the response
“6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.”

Source location
2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Page 2 · response
Published 25 June 2015
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of a system for flagging discrepancies between drug prescription and administration

Linked response

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation

Lack of a protocol for easily checking medication discrepancies

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Stated actions 2

Respondent positions 1

Stated actions 7