Medication dispensing and dispatch errors not reliably detected
First to latest report 27 Jan 2014 — 28 Nov 2024
Reports that mention this concern
5
Times this concern has been raised
7
Stated actions linked to this concern
12
What this concern includes
Includes failures of checking, assurance or operational controls dedicated to detecting and correcting errors during medication dispensing or dispatch, including errors identified after prescribing where the dispensing process is implicated.
What is not included
Excludes prescribing errors with no dispensing or dispatch-control component.
Excludes medication administration errors unless the failure concerns an upstream dispensing or dispatch control.
Excludes generic incident-reporting, documentation or learning failures not explicitly tied to detecting or correcting medication dispensing or dispatch errors.
Excludes ambulance or other emergency-service dispatch concerns.
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.
Medicines and Healthcare products Regulatory Agency2
Clare House Surgery1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
General Pharmaceutical Council1
NHS England1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Nursing and Midwifery Council1
Pharmacy2U Limited1
Royal Pharmaceutical Society1
Royal Pharmaceutical Society of Great Britain1
Health and care professional regulator2
Health professional body2
Medicines and medical devices regulator2
Executive non-departmental public body1
Healthcare site1
Integrated care board1
Local health board1
Ministerial department1
NHS trust1
Private limited company1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
Devon, Plymouth and Torbay
Concerns raised1
Medication dispatch failing to allow mistakes to be noticed and remedied
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Partners of Amicus Health Group
Pharmacy2U
Royal Pharmaceutical Society
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
Partners of Amicus Health Group
Monitor rejected electronic cancellation notifications daily and act on them when required.
Partners of Amicus Health Group
Eliminate non-auditable messaging systems for clinical information in prescription management.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Royal Pharmaceutical Society
The benefits of efficient, timely medicine supply outweigh the risks because prescribers should complete clinical appropriateness assessments before issuing prescriptions.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pharmacy2U
Existing dispensing processes and required reasonable promptness are considered sufficient; planned delays to allow post-prescribing checks would be unsafe and disproportionate.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Partners of Amicus Health Group
The practice cannot easily cancel prescriptions after pharmacy download because cancellation routes and pharmacy communications are not sufficiently accessible.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Partners of Amicus Health Group
Changing online pharmacies’ rapid prescription dispatch and automatic drawdown is outside the practice’s scope.
Outside remitThe respondent said that this matter was outside its role or authority.
Partners of Amicus Health Group
Online pharmacies and relevant regulatory bodies are asked to review and improve prescription cancellation and communication processes.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Wales Central
Concerns raised1
Failure to detect prescribing and dispensing errors at discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of pharmacy checks to prevent inadvertent dispensing to vulnerable adults
Linked responses
Medicines and Healthcare products Regulatory Agency
NHS Greater Manchester 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
Medicines and Healthcare products Regulatory Agency
Issue best-practice guidance recommending differentiated medicine packaging to reduce selection errors.
Medicines and Healthcare products Regulatory Agency
Publish a Drug Safety Update article reminding healthcare professionals to remain vigilant for medicine-name confusion errors.
Medicines and Healthcare products Regulatory Agency
Review atenolol and amitriptyline packaging for potential improvements that could reduce future dispensing errors.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS Greater Manchester Integrated Care Board
Community pharmacy services fall outside the respondent’s responsibility.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS Greater Manchester Integrated Care Board
NHS England is responsible for community pharmacy services.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS Greater Manchester Integrated Care Board
The key safety issue is pharmacy dispensing, not carers’ clinical qualifications or medication-administration responsibilities.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Failure of pharmacy-to-ward medication transfer procedures to require receipt checks against packaging, labelling and prescription charts
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Northern Care Alliance 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.4
Northern Care Alliance NHS Foundation Trust
Implement closed-loop dispensing by linking electronic prescribing, pharmacy dispensing and robotic systems.
Northern Care Alliance NHS Foundation Trust
Implement closed-loop medication administration using electronic barcode scanning of patients and medications.
Northern Care Alliance NHS Foundation Trust
Update accuracy-checking procedures to require a second check for all intravenous fluids.
Northern Care Alliance NHS Foundation Trust
Ensure nursing staff recognise different Polyfusor products and check all medication details in full.
York City
Concerns raised3
Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Failure of colleague checking to prevent dispensing medication errors
Lack of mandatory read-back procedures for dispensing details
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
General Pharmaceutical Council
NHS England
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
NHS England
Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
NHS England
Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
General Pharmaceutical Council
Highlight existing dispensing-error guidance, including involving two people where possible, in the next Regulate+ newsletter.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Department of Health and Social Care
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
General Pharmaceutical Council
The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
NHS England
Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.