First reported 29 Feb 2016•Latest report 2 Jun 2024
Definition
What this concern includes
Includes failures in the dispensing-packaging process that affect the suitability, integrity, clear identification or patient-specific differentiation of dispensed medicines and compliance aids, including unsafe transfer from original unit-dose packaging and insufficient differentiation of medication packs for people living together.
Not included
Excludes prescribing, dose selection and clinical medication-review failures where dispensing packaging or identification is not the deficient control.
Excludes medication administration failures after the dispensed medicine and its intended patient have been reliably identified.
Excludes generic medication shortages, supply delays, storage failures and disposal failures not involving packaging or identification of dispensed medicines.
Excludes general record-keeping or communication deficiencies unless they directly impair the packaging, identity or patient-specific differentiation of dispensed medication.
Reports
4
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2016–2024
First to latest report issue date
Stated actions
11
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.
General Pharmaceutical Council2
Community Pharmacy England1
Community Pharmacy Thames Valley1
Dispensing Doctors' Association Limited1
Haverhill Pharmacy1
Medicines and Healthcare products Regulatory Agency1
National Pharmacy Association1
NHS Frimley Integrated Care Board1
NHS Specialist Pharmacy Service1
Public Health England1
Royal Pharmaceutical Society1
Slough Pharmacy1
Swansea Bay University Local Health Board1
Health and care professional regulator2
Healthcare site2
Executive agency1
Health professional body1
Health-sector membership body1
Integrated care board1
Local health board1
Medicines and medical devices regulator1
NHS provider group1
Professional membership body1
Trade association1
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.
Berkshire
Concerns raised1
Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Consider adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.
Stated by NHS Specialist Pharmacy ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Review existing guidance and consider refinements for supporting patients with cognitive impairments.
Stated by National Pharmacy AssociationStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Raise the risk of confusing multi-compartment aids in one household with the Royal Pharmaceutical Society and request consideration of additional guidance or information.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Raise the risk of confusing multi-compartment aids in one household with the Community Pharmacy Patient Safety Group and request consideration of additional guidance or information.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Inform represented community pharmacy owners about the risk of confusing multi-compartment aids in one household.
Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
Action
Double-check each tray with the patient after removing it from packaging.
Stated by Wexham Road pharmacyStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
Action
Provide differently branded trays with distinct packaging to households where multiple people use trays.
Stated by Wexham Road pharmacyStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.9
Position
Community pharmacies are independent contractors under a national framework, limiting the ICB’s direct influence over their processes.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Different dosette or label colours are not currently available because legal labelling requirements limit community pharmacy options.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Pharmacy dispensing concerns fall outside the medicines regulator’s remit, which covers medicines placed on the UK market.
Stated by MHRA Customer Experience CentreOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about pharmacists’ dispensing actions should be addressed to the General Pharmaceutical Council, the pharmacy and pharmacist regulator.
Stated by MHRA Customer Experience CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for labelling dispensed medicines lies with the regulator, so the service does not provide labelling information.
Stated by NHS Specialist Pharmacy ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Dispensing medication is governed by a national pharmacy contract agreed and negotiated nationally, rather than by the local pharmacy committee.
Stated by Thames Valley LPCOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for commissioning dispensing medication rests with Frimley ICB, which has raised the matter with NHS England.
Stated by Thames Valley LPCRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Community pharmacies operate as independent contractors under national contracts, limiting direct influence over their processes.
Stated by NHS Frimley Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Different dosette or label colours are not currently available because community-pharmacy dosettes must meet legal labelling requirements.
Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Suffolk
Concerns raised1
Failure to dispense prescribed methadone in single daily dosage bottles
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Develop and publish COVID-19 guidance for drug and alcohol treatment providers addressing infection risks and medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Strengthen individualised risk-assessment requirements in subsequent iterations of published guidance before changing medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Reiterate to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements.
Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Action
Continue supplying methadone in individual dose containers as the pharmacy’s standard procedure.
Stated by Haverhill PharmacyStated completedThe respondent said that this action was complete when they made their response on 5 January 2021.
Swansea and Neath Port Talbot
Concerns raised1
Unsuitability of Nomad trays for dispensing medication to some patients
This report raised 2 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Lincolnshire
Concerns raised1
Failure to comply with professional advice against placing snipped tablets in multi-dose compliance aids
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in the dispensing-packaging process that affect the suitability, integrity, clear identification or patient-specific differentiation of dispensed medicines and compliance aids, including unsafe transfer from original unit-dose packaging and insufficient differentiation of medication packs for people living together.
