Recurring concern
Failure to reliably learn from medication incidents and implement safeguards
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Request correctionFirst reported 7 May 2024•Latest report 19 Mar 2026
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.
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.
- Reports
- 5
- Individual concerns
- 5
- Date range
- 2024–2026
- Stated actions
- 8
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Review reported incidents, provide feedback, and operate PSIRF-based divisional incident review and escalation processes.
Stated by St George’s, Epsom and St Helier University Hospitals and Health Group
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 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.
Responses linked to these concernsEach 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
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Action
Share learning from the opioid analgesia incident with Emergency Department colleagues to inform future practice.
Stated by Mid and South Essex NHS Foundation Trust
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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Position
Opioid analgesia was within acceptable clinical decision-making, so further review or safeguarding was not considered necessary.
Stated by Mid and South Essex NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.5
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Action
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
Stated by NHS England -
Action
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Stated by NHS England -
Action
Share the report with Agilio Software for awareness.
Stated by National Institute for Health and Care Excellence
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Action
Present the incident and related learning at the cardiology Grand Round.
Stated by The Trust -
Action
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Stated by The Trust
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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Position
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Stated by Department of Health and Social Care
Data last updated 7 September 2026