Recurring concern

Inadequate safeguards for medication-safety software overrides

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First reported 15 Jun 2018•Latest report 25 Nov 2021

Definition

What this concern includes

Includes failures of medication-safety or prescribing software controls involving inappropriate override authority, missing limits or escalation, inadequate justification, or absent documentation of overrides.

Not included

Excludes failures of non-medication software or systems unless the report explicitly ties them to medication-safety overrides.
Excludes general documentation, training, staffing or governance deficiencies that are not specifically dedicated to controlling medication-safety software overrides.
Excludes clinical decisions to override guidance or treatment plans where no medication-safety software override is involved.
Excludes software failures unrelated to override control, such as failure to recognise a clinical condition, unless the unsafe condition is specifically an inadequately controlled medication-safety override.

Reports: 2
Individual concerns: 2
Date range: 2018–2021
Stated actions: 6

Reports 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.

John Radcliffe Hospital1

NHS Brighton and Hove Clinical Commissioning Group1

NHS Surrey and Sussex Integrated Care Board1

North Laine Medical Centre1

Oxford University Hospitals NHS Foundation Trust1

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.

25 Nov2021
Berkshire
Concerns raised1
1. Failure to define and document overrides of medication-safety software
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Educate staff to use medication libraries and not bypass safety limits except in exceptional circumstances.
  Stated by Oxford University Hospitals NHS Foundation TrustStated planned
2. Action
  Devise and document an escalation process, standard operating procedure and quick-reference flowsheet for exceptional medication-library overrides.
  Stated by Oxford University Hospitals NHS Foundation TrustStated planned
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
Failure to define and document overrides of medication-safety software
Wider context from the report
“3. Whether software like Guardrails should be implemented more widely, and consideration given to when and how it is possible to override this, and how that should then be documented. ”
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
Educate staff to use medication libraries and not bypass safety limits except in exceptional circumstances.

Verbatim wording from the response
“Each medication library will contain a list of medications with specified concentrations and/or dosing safety limits to reduce the risk of infusion related incidents e.g., overdosing or underdosing. Resource will be allocated to ensure that medication entries on the libraries are accurate, relevant, and appropriate so that staff should not need to override safety limits if following usual practice; the software is designed not to be overridden if inappropriate dosing is entered outside of the safe limits put in place.”

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
Devise and document an escalation process, standard operating procedure and quick-reference flowsheet for exceptional medication-library overrides.

Verbatim wording from the response
“However, in some exceptional circumstances outside the norm, it may be necessary for patient care to deviate from the specified dosing limits and therefore the infusion pumps offer the capability to infuse medication outside of the library where safety limits are not imposed. Staff will be educated that they must not work outside of the medication library unless in exceptional circumstances and an escalation process will be devised to enable a clear audit trail of all communication and decisions made between staff members which will be documented in the patients’ medical notes. This will be detailed in a standard operating procedure and will contain a flowsheet of the escalation process as a quick reference guide for staff members. A working group has been set up on NICU, who already use a medication library, to trial this.”

Source location
2021-0399-Response-from-Oxford-University-Hospitals_Published
Page 2 · response
Published 29 November 2021
Open published response
15 Jun2018
Brighton and Hove
Concerns raised1
1. Failure of prescribing-system warnings to prevent inappropriate override
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 4
1. Action
  Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
3. Action
  Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.
  Stated by North Laine Medical CentreStated completed
1. Action
  Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.
  Stated by North Laine Medical CentreStated in progress
AI-generated summary

Darren James CARRINGTON · 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

Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.

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 of prescribing-system warnings to prevent inappropriate override
Wider context from the report
“The method of prescribing medication such as Zopiclone (in this case), Codeine, Morphine, Benzodiazepines etc. to patients which suggests that they either are or are very likely to be becoming dependent upon such medications or are misusing them. Examples of both the above would be too frequent requests for repeat prescriptions and information concerning a history of overdoses. The Inquest discussed whether circumstances, including those outlined above should trigger an automatic/mandatory medication review conducted with the patient; consideration of a different prescribing period and very careful monitoring of the online requests for repeat prescriptions. Alternatively, there could be a ban on the requests for repeat prescriptions with the repeats simply being issued for an appropriate period of time “automatically”. In this case as you will see from ████████ report, over twice the appropriate amount of Zopiclone was issued over a period of 57 days. The patient in question had Zopiclone present at a fatal level in his blood at the time of his collapse from which he never recovered. I remain very worried about these prescribing issues and about the fact that apparently receptionists and clinicians can override the warnings in the surgery’s computer system. I should like this to be carefully investigated and look forward to hearing with a response within the relevant time period. I realise that the situation may be exacerbated by GPs working part time and many part time practitioners being involved in the prescribing procedure as well as many receptionists being involved in it but if this is the trend then it seems to me the safeguards must be extended not made easier to override. The other ‘failsafe device’ is the dispensing pharmacist. When repeats are requested online there is a designated pharmacy. They receive emailed scripts. Their own systems should flag up cases of over or too frequent prescribing as well as other matters. ”
Source location
Darren James CARRINGTON · 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
Review high-risk prescribing records and remove online prescription-request access for weekly, controlled, dependency-forming and potentially abusive medicines.

Verbatim wording from the response
“• Records of all patients receiving weekly prescriptions have been reviewed and access to on-line requests have been removed.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Lower computer-alert thresholds for early prescription ordering and increase awareness of relevant alerts.

Verbatim wording from the response
“• Computer settings changed with a view to lower thresholds for flagging up early ordering of scripts and increased awareness around the potential significance of these and other alerts.”

Source location
2018-0181-Response-from-Commission-Alliance-
Page 2 · response
Published 8 July 2018
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
Change computer-system thresholds so early-order warnings appear one day before due dates and online ordering closes three days before due dates.

Verbatim wording from the response
“4. An investigation into online ordering and script generation by the computer system was conducted in conjunction with the practice IT co-ordinator. As a result, the timings were changed within the system so that warnings about scripts being ordered too early were changed from 7 to 1 day and ordering online from 10 to 3 days.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
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
Develop a computer-generated warning identifying patients with overdoses or suicide attempts when high-risk medicines are requested.

Verbatim wording from the response
“10. A further meeting is planned with the practice IT coordinator to highlight automatically patients who have taken an overdose when certain high-risk drugs are requested. We hope to have this in place shortly.”

Source location
2018-0181-Response-from-North-Laine-Medical-Centre
Page 2 · response
Published 8 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to define and document overrides of medication-safety software

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.2

Concerns raised1

Failure of prescribing-system warnings to prevent inappropriate override

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

Actions described in response 2

Actions described in response 4