Recurring concern
Failure to reliably learn from medication incidents and implement safeguards
- Reports that mention this concern
- 5
- Times this concern has been raised
- 5
- Stated actions linked to this concern
- 8
What this concern includes
Includes failures in the dedicated medication incident learning and governance process, including incident follow-up, review, identification of safeguards, and implementation or communication of medication-safety learning.
What is not included
- Excludes generic incident investigation or organisational learning failures not explicitly concerning medication incidents.
- Excludes failures in medication prescribing, administration, monitoring or allergy checking unless the asserted deficiency is specifically the subsequent medication incident learning or safeguard process.
- Excludes general communication or follow-up failures that are not tied to medication incident learning.
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 5 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Failure to follow up medication incidents for learning affecting vulnerable patients
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Community 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.1
-
Sussex Community NHS Foundation Trust
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
-
Concerns raised1
Lack of investigation of medication maladministration concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- St George’s, Epsom and St Helier University Hospitals and Health Group
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
-
St George’s, Epsom and St Helier University Hospitals and Health Group
Review reported incidents, provide feedback, and operate PSIRF-based divisional incident review and escalation processes.
-
Concerns raised1
Failure to learn lessons from potentially dangerous medication supply intervals
This report raised 4 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.
-
Concerns raised1
Failure to review medication safety incidents and raise safeguards
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Mid and South Essex 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.1
-
Mid and South Essex NHS Foundation Trust
Share learning from the opioid analgesia incident with Emergency Department colleagues to inform future practice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Mid and South Essex NHS Foundation Trust
Opioid analgesia was within acceptable clinical decision-making, so further review or safeguarding was not considered necessary.
-
Concerns raised1
Failure to specify and disseminate learning from the DOAC pausing incident
This report raised 4 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
- National Institute for Health and Care Excellence
- NHS England
- The 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.5
-
NHS England
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
-
NHS England
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
-
National Institute for Health and Care Excellence
Share the report with Agilio Software for awareness.
-
The Trust
Present the incident and related learning at the cardiology Grand Round.
-
The Trust
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026