High-risk medication monitoring
Inadequate or absent arrangements for monitoring patients prescribed high-risk medicines, leading to potential harm.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Mohammed Hussain
The coroner identified inadequate systems for monitoring and communicating high clozapine levels, and a lack of staff understanding in interpreting and responding to them. This included ineffective medication change processes and insufficient learning from previous concerns.
Matched on
terms: high, medication, monitoring
CQC action
83match
Charlton House Medical Centre
Arrangements for monitoring patients prescribed high risk medicines continued to place patients at risk of harm.
Matched on
terms: high, monitoring
CQC action
81match
The Sidings Medical Practice
Improve the process for the monitoring of patients in receipt of high-risk medication.
Matched on
terms: high, medication, monitoring
PFD report
77match
Nathan Cooke
The coroner noted the absence of a formal process for primary care practices to manage patients prescribed medication requiring regular monitoring, particularly when patients do not attend reviews.
Matched on
terms: medication, monitoring
PFD report
77match
Sarah Brady
The coroner noted concerns regarding a hospital issuing a 14-day prescription for medication already prescribed by the GP, which contradicted the GP's practice of issuing 7-day prescriptions to a patient with a high overdose risk and erratic compliance. This additional prescription may have contributed to medication stockpiling.
Matched on
terms: high, medication
PFD report
77match
William Northcott
The coroner noted a disparity in monitoring and discussion of Clozapine side effects for patients attending GP practices compared to specialist clinics, highlighting this as a potential national issue. There was also insufficient focus on cardiomyopathies like left ventricular hypertrophy in Clozapine guidance, which is based on national recommendations.
Matched on
terms: high, monitoring
HSSIB recommendation
77match
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital
Caring for older patients in hospital often presents a high-risk situation for medication errors occurring. Further efforts should be made to learn from technological developments and the organisation of pharmacy services in other high-risk areas of care that may improve system resilience in older persons care.
Matched on
terms: high, medication
CQC action
77match
Penn Manor Medical Practice
Continuetoimprovethemonitoringandreviewofpatientsprescribedhighriskmedicines.
Matched on
terms: high, monitoring
PFD report
73match
Thomas Thurling
The coroner identified inadequate monitoring of a change in medication, a lack of review or alternative care coordinator during an extended absence, and staffing shortages within the Trust.
Matched on
terms: medication, monitoring
PFD report
73match
Marjorie Bassendine
The coroner noted concerns about the potential for multiple psychotropic medications to prolong the QT interval, highlighting the importance of pre-treatment and regular ECGs to monitor for long QT syndrome.
Matched on
terms: high, medication
PFD report
73match
Astonn Mitchell-Male
The Trust lacked a policy for monitoring patient medication compliance and triangulating information in community settings. There were also concerns about poor and non-existent record-keeping, impacting communication and patient safety.
Matched on
terms: medication, monitoring
PFD report
73match
Liane Davenport
The coroner raised concerns regarding whether monitoring blood levels of powerful antipsychotics should be considered for patients on long-term high-dose treatment, particularly as they become older and more frail.
Matched on
terms: high, monitoring
PFD report
73match
Malcom Garrett
The coroner noted a lack of specific guidance for managing immunosuppressed patients at high risk of Covid-19 in a hospital setting, including expediting their discharge or exploring alternative treatments. There was also a need for greater monitoring of kidney function to prevent opiate toxicity.
Matched on
terms: high, monitoring
PFD report
73match
Amanda Kramer
The coroner noted that Mrs Kramer was prescribed Zopiclone, a short-term medication, for 18 years without clear evidence of review by her GP or mental health trust, even following instances of high-risk behaviour.
Matched on
terms: high, medication
PFD report
73match
Malcolm Garrett
The coroner noted the absence of specific guidance for managing and expediting discharge of high-risk immunosuppressed patients in acute hospital settings. Concerns were also raised about insufficient monitoring of kidney function, which contributed to opiate toxicity and delayed discharge.
Matched on
terms: high, monitoring
Scottish FAI
71match
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter....
Matched on
terms: medication
PFD report
69match
Hireiti Kuflesion
The coroner noted pregnant patients with mechanical heart valves sometimes receive insufficient Clexane doses and inadequate anti-factor Xa monitoring. There was also a lack of understanding among clinicians across the region regarding the increased thrombosis risk for these patients, potentially delaying diagnosis.
Matched on
terms: monitoring
PFD report
69match
Ann Coles
The coroner noted the absence of a requirement for regular lung imaging in patients prescribed long-term amiodarone, despite the medication's potential to cause lung toxicity and fibrotic changes.
Matched on
terms: medication
PFD report
69match
Teresa Bennett
The coroner noted a lack of compliance with medication review targets in GP practices and no standard practice for reviews, leading to variation between clinicians. This raised concerns about the risk of inadvertent overdose when central nervous system depressants are co-prescribed without regular review or specific patient advice.
Matched on
terms: medication
HSSIB recommendation
69match
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts.
Matched on
terms: high, medication
HSSIB recommendation
66match
Medication not given: anticoagulation before and after a procedure
Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
Matched on
terms: medication
PFD report
65match
Judith Saville
The coroner identified that medication prescribing did not sufficiently account for a patient's overdose history, and a computer warning system for practitioners was absent. Concerns were also raised about the lack of implementation and auditing of an action plan from a Root Cause Analysis.
Matched on
terms: medication
PFD report
65match
William Bows
There were no protocols or guidance for primary care providers on monitoring patients prescribed Amiodarone for liver, thyroid, and respiratory functions. The coroner also noted insufficient monitoring by prescribers during the initial 12 months when toxicity commonly develops.
Matched on
terms: monitoring
PFD report
65match
Megan Jones
The coroner identified a lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding regular QTc recording, which is particularly crucial for those prescribed high doses.
Matched on
terms: high
PFD report
65match
Christopher Summerhayes
The coroner raised concerns regarding the prescription of Clozapine alongside numerous other medications, leading to significant weight gain and potential cardiovascular issues, and the lack of consideration for familial lipid disorders that might contraindicate its use.
Matched on
terms: medication
PFD report
65match
Eirwen Hollister
The GP practice lacked a process to ensure a full review by a GP before issuing further prescriptions after a patient had overdosed on prescribed medication.
Matched on
terms: medication
PFD report
65match
Colin Greenway
Concerns were raised regarding junior doctors' incorrect prescribing despite clear guidelines and inadequate VTE assessments. The coroner also noted consultants not accepting responsibility for monitoring junior doctors' prescribing, and a lack of continuity of care for patients.
Matched on
terms: monitoring
PPO recommendation
64match
Manx Care
Manx Care should ensure that patients who come in with complex and high-risk medication (as per the RCGP guidance) have a medication review when they arrive at the prison.
Matched on
terms: high, medication
PPO recommendation
64match
The Head of Healthcare
The Head of Healthcare should ensure that when high or medium risk medications such as amitriptyline are prescribed, the prescriber ensures that a further in-possession risk assessment takes place in line with local and national policy.
Matched on
terms: high, medication
PFD report
61match
Lucy Kilvert
The coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Matched on
terms: medication
PFD report
61match
Linda Hudson
Concerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Matched on
terms: medication
PFD report
61match
Stephen Ellis
The coroner suggested it would be good practice to supply warfarin home management kits to high-risk patients who have undergone heart surgery and are subsequently on warfarin.
Matched on
terms: high
PFD report
61match
Moses McDonald
The coroner noted a lack of mandatory and regular glucose testing for patients on antipsychotic medication by the Clozapine clinic.
Matched on
terms: medication
PFD report
61match
Laurence Boyens
Coroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Matched on
terms: monitoring
PFD report
61match
Dorothy Delaney
The coroner noted Alexander House Health Centre's practice of prescribing concurrent antiplatelet and anticoagulant medications without seeking individual specialist advice, instead relying on general advice for other patients.
Matched on
terms: medication
PFD report
61match
Wayne O’Neill
The coroner noted a lack of recognition among clinicians regarding a specific medication's contraindication for asthma and the risks associated with a combination of psychotropic drugs. Concerns were also raised about the absence of routine ECG screening for prisoners prescribed this medication combination.
Matched on
terms: medication
PFD report
61match
Amanda Spark
The coroner noted a gap in communication where changes to a patient's mental health medication regime, supervised by the Crisis team, did not trigger corresponding action or review regarding their physical health medication.
Matched on
terms: medication
PFD report
61match
Bruce Houghton
The coroner noted that the deceased had not received an annual medication review, and that such reviews do not routinely include enquiries about over-the-counter medications taken alongside prescribed ones.
Matched on
terms: medication
PFD report
61match
Evelina Vilkiene
The coroner identified gaps in risk assessment and management plans during the patient's transition between mental health teams and when medication was weaned. Further concerns included the absence of required care co-ordinator reviews for an amber zoned patient.
Matched on
terms: medication
PFD report
61match
John James
The coroner noted that the refusal of anti-coagulation medication was not brought to the attention of medical staff. There is no electronic prompt or alert to notify the medical team when prescribed anti-coagulation medication is not administered.
Matched on
terms: medication
PFD report
61match
Kelly Stevens
The coroner identified a lack of overall consultant responsibility for a medical outlier patient and no Trust policy to address this. Concerns also included insufficient monitoring of electrolytes and fluid balance, and outdated care plans due to routine copying and pasting.
Matched on
terms: monitoring
CQC action
61match
Moorcroft Medical Centre
Evaluate and embed the changes implemented during the inspection. For example, older medicine safety alert system searches, monitoring and coding systems for prediabetes patients and the reintroduction of downloading electronic pathology results prior to repeat prescribing.
Matched on
terms: monitoring
HSSIB recommendation
60match
Potential under-recognised risk of harm from the use of propranolol
Safety action by NHS England/NHS Improvement In March 2019, NHS England wrote to ambulance trusts in England regarding the management of cases where patients have self-harmed and are at risk of suicide. This included specific reference to patients who may have taken an overdose of medication. The letter acknowledged that there were varying models in place for the...
Matched on
terms: medication
PFD report
57match
Labhuden Amarshi Vaghadia
The coroner raised concerns about a community nurse administering anticoagulant medication without seeking medical advice despite previous bleeding, and failing to share this information with other professionals. The report also identified a lack of the nurse's professional insight and training.
Matched on
terms: medication
PFD report
57match
Bridget Cahill
The coroner raised concerns about a patient experiencing a morphine overdose despite receiving less than the maximum prescribed dose. Attention was drawn to whether recommended maximum doses should consider factors like body weight, co-morbidities, and potential drug buildup in the body for long-term therapy.
Matched on
classifier match
PFD report
57match
Margaret Hions
The coroner noted a need to review tinzaparin prescribing practices and blood level monitoring, alongside reiterating the importance of monitoring creatinine clearance according to Health Board policy.
Matched on
terms: monitoring
PFD report
57match
Ann Jacobs
The coroner noted insufficient monitoring of potassium levels every 8 hours following a diagnosis of severe hypokalaemia and a lack of adherence to the Trust's acute hypokalaemia management guidance.
Matched on
terms: monitoring
PFD report
57match
Steven Allen
The coroner noted concerns regarding the prescribing of oxycodone and other medications to an individual with a history of addiction, especially when prescriptions were issued via telephone consultations and replacement prescriptions were given with little challenge.
Matched on
terms: medication
CQC action
57match
Ellesmere Port Hospital
The trust should review the prescribing of medicines that control distressed behaviour to ensure the policy is followed and monitoring is completed.
Matched on
terms: monitoring
CQC action
57match
St Helens Hospital
Continuetomonitorpatientmedicationreviews.
Matched on
terms: medication