MAR chart errors
Failures in accurately completing medication administration record (MAR) charts, indicating risks in medication management.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
82match
Judith Marshall
The coroner noted concerns regarding the policing of internal pharmacy error records and the lack of mandatory read-back procedures or software to prevent dispensing mistakes. There is also no central database for monitoring prescription errors.
Matched on
terms: error, mar
CQC action
77match
Victoria Infirmary
The service should continue to maintain complete records of photographic identification in children’s medication charts used in special schools.
Matched on
terms: chart, mar
PFD report
74match
Marie Quinn
The coroner identified concerns regarding medication management at Richmond House Nursing Home, where excess medication was not queried. Inaccurate hospital discharge notes led to the premature cessation of prophylaxis treatment for a patient.
Matched on
terms: mar
CQC action
74match
Cumberland Infirmary
The trust must ensure the timely administration and accurate recording of all medications, including oxygen, prescribed to patients under its care. Regulation (1)(2)(c)(g).
Matched on
terms: mar
PFD report
73match
Beatrice Gatt
An error in transferring medication details between Mars sheets led to Mrs Gatt not receiving her anti-psychotic medication, with the coroner noting a lack of formal training for nursing staff on these procedures.
Matched on
terms: error, mar
PFD report
70match
Mary Bloom
The coroner identified non-compliance with Trust policy for heparin administration, specifically regarding weighing the patient, consulting haematology for low weight, and re-attempting baseline bloods. Critical information for underweight patients on the heparin poster was also not sufficiently visible.
Matched on
terms: mar
PFD report
69match
Malcolm Rathmell
An incorrect warfarin prescription, resulting from a mislabelled anti-coagulation chart, went unidentified by multiple medical professionals for several days and lacked ward-based pharmacy review. The Trust's proposed actions to address such prescribing errors are still in early stages of implementation.
Matched on
terms: chart, error
PFD report
66match
Tripta Rani Kumar
The patient's medical notes were altered, removing a documented penicillin allergy without signature or verification, which led to a penicillin-containing antibiotic being prescribed and posed a risk of anaphylactic shock.
Matched on
terms: mar
PFD report
65match
Lee Hollman
The coroner identified concerns regarding the maintenance of accurate and updated medical records, specifically relating to medication details. There was also a lack of an effective system for issuing repeat prescriptions and reviewing patients according to guidelines.
Matched on
terms: mar
PFD report
65match
Colin Ireland
The coroner noted an inadequate discharge summary that failed to clarify medication status and the risks of late Friday discharges without assured weekend healthcare provision. Gaps in medication administration and venous thromboembolism risk assessments were also identified.
Matched on
terms: mar
PFD report
65match
Fred Whittaker
The medical centre continued prescribing a drug in error after a request to stop it, because there was no mechanism to record the reasons for discontinuing medication in clinical records. This practice may be replicated in other GP practices.
Matched on
terms: error
PFD report
65match
James Quinton
Poor quality nursing notes and observation charts hindered consultants' understanding of patient events. The coroner also identified a lack of checking procedures for verbally prescribed medications, which led to an incorrect drug administration.
Matched on
terms: chart
PFD report
65match
Cuthbert Hingert
The coroner identified several medication errors, including duplicate antiplatelet prescribing and an incorrect aspirin dosage, alongside a delay in documenting a prescribing decision. Concerns were also raised about insufficient clinician training in the medicines database and a nurse's failure to follow incident reporting protocol for errors.
Matched on
terms: error
Scottish FAI
63match
Linda Allan
8. In terms of section 26(4), I make the following recommendations: 1. Every post-operative patient should be seen by an ANP or a doctor and their presentation recorded in the observation notes on a daily basis. As part of that daily review, the medication prescribed to the patient should be considered and adjusted if appropriate. The observation record...
Matched on
terms: chart, mar
PFD report
61match
Harold Goulding
Communication broke down between the anti-coagulation clinic, the GP, and the care home regarding a resident's new GP details. Additionally, the General Practitioner did not consider the Medication Administration Record held by the home during new resident reviews, indicating a lack of a system for medication approval.
Matched on
classifier match
PFD report
61match
Scott Hooper
The coroner noted an incorrect weight recording, impacting anti-coagulant dosage, and a lack of clear documentation for clinical decisions. Further concerns were raised about the insufficient dissemination of lessons learned and the absence of a plan for weight estimation training.
Matched on
terms: mar
PFD report
61match
Ahsiyah Bibi
The coroner noted delays in identifying high potassium due to blood gas results being separated from records, and a drug error occurred with insulin prescribing for hyperkalaemia, for which there had been no Trust-wide review of the risks.
Matched on
terms: error
PFD report
61match
Jennifer Midgley
The drug administration chart does not clearly differentiate between oral and intravenous paracetamol, nor does it include a patient's weight reference for intravenous administration, which is needed to modify dosage.
Matched on
terms: chart
PFD report
61match
Andrew Craig
The coroner identified ongoing issues with the use of prescription and illicit drugs at HMP Guys Marsh, noting that the chaotic medication dispensing process at the healthcare hatch allows for drug transfer and redistribution among prisoners.
Matched on
terms: mar
PFD report
61match
Gwyneth Edwards
The coroner noted that staff recorded National Early Warning Scores (NEWS) but did not action them according to protocol, and a Mobile Medic request was marked complete without attendance. Concerns also included insufficient staffing impacting patient monitoring and record-keeping.
Matched on
terms: mar
PFD report
61match
Kalma Ram-Henman
The coroner identified concerns regarding incomplete fluid charts, failure to administer prescribed potassium and intravenous fluids, and missed opportunities to monitor and recognise patient deterioration due to inadequate reading of notes during transfer.
Matched on
terms: chart
CQC action
61match
Aspirations (Northampton)
The recording of administration of medicines required improvement. Medicine administration records [MAR] had not been consistently signed or transcribed in line with best practice.
Matched on
terms: mar
CQC action
60match
The Everley Residential Care Home
We recommend that people’s MAR charts are signed by staff after the medication has been witnessed as being taken.
Matched on
terms: chart, mar
PFD report
57match
Kerry Jacobs
The coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Matched on
terms: mar
PFD report
57match
Terence Stilges
The coroner identified a practice of writing discharge summaries in advance, which led to a patient being discharged prematurely before all necessary test results, including a second troponin, were available.
Matched on
terms: mar
PFD report
57match
Joyce Rumming
The coroner identified gaps in communication between different software packages, leading to a patient's allergy marker being missed and an antibiotic administered despite a known allergy.
Matched on
terms: mar
PFD report
57match
Craig Hamilton
The coroner identified a lack of clear procedures for managing and monitoring patients who seek to obtain more medication than prescribed, and for exploring alternative pain management during reviews. Concerns were also raised about systems for discussing dosage implications with patients and recording such discussions.
Matched on
classifier match
PFD report
57match
Songul Bozdag
The coroner noted gaps in the care co-ordinator's mandatory reviews and record-keeping for Ms Bozdag, including unrecorded discussions and failure to update her drug card, resulting in under-medication.
Matched on
classifier match
PFD report
57match
Daphne Penn
The coroner noted a more rapid steroid reduction rate was initiated than originally suggested, a delay in transmitting family concerns about the patient's condition to medical staff, and an additional decrease in steroid dose due to a prescribing error.
Matched on
terms: error
PFD report
57match
Angela West
The coroner noted that the patient's high-risk surgery was scheduled for a Thursday, meaning post-operative care occurred under weekend staffing. Concerns were also raised about the patient's location on a general surgical ward and a lack of fluid balance charts during dehydration.
Matched on
terms: chart
CQC action
57match
Queen's Medical Centre
The trust should ensure that weights are recorded on medicines charts.
Matched on
terms: chart
CQC action
57match
Nottingham City Hospital
The trust should ensure that weights are recorded on medicines charts.
Matched on
terms: chart
CQC action
57match
Derriford Hospital
The service must ensure adequate standards of documentation is maintained, including but not limited to: CTG monitoring, patient observations, medicine charts and handover of care. The service must ensure that patient records are stored securely at all times.
Matched on
terms: chart
CQC action
57match
Doncaster Royal Infirmary
The trust must ensure staff follow the proper and safe management of medicines, and the service uses systems and processes to prescribe and administer medicines safely.
Matched on
terms: mar
PFD report
53match
Jill Sinson
The coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Matched on
classifier match
PFD report
53match
Jennifer Tompkins
The coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
Matched on
classifier match
PFD report
53match
Lottie Reid
The coroner noted a discrepancy between medication records following hospital discharge and a lack of a protocol to easily check such discrepancies, particularly on weekends.
Matched on
classifier match
PFD report
53match
Thomas Farrell
The care home did not obtain a complete record of prescription drugs from the resident's GP, resulting in some medications not being administered.
Matched on
classifier match
PFD report
53match
Betty Addison
The coroner raises concerns about insufficient control over medication administration and monitoring at Alexandra Court Care Home, noting that residents may receive incorrect amounts of prescribed medication.
Matched on
classifier match
PFD report
53match
Ronald Brewer
Concerns were raised regarding the administration of medications, with particular note on the documentation and dispensation of palliative medications.
Matched on
classifier match
PFD report
53match
Michalla Sweeting
The coroner highlighted that handovers for prisoners undergoing detoxification must include all patients and a registered nurse's review of records. Further concerns related to ensuring observations are taken closer to medication dispensing times to inform staff.
Matched on
classifier match
PFD report
53match
Michael Drewell
A senior clinician's advice on medication duration was not followed and was not transferred to electronic patient notes. This created a gap as junior doctors, who are not expected to consult handwritten records for prescribing, consequently missed critical information.
Matched on
classifier match
CQC action
53match
Russells Hall Hospital
The trust should ensure that medicines charts are completed correctly.
Matched on
terms: chart
CQC action
53match
Kidderminster Hospital and Treatment Centre
Ensure medicine charts are audited to include missed doses.
Matched on
terms: chart
CQC action
53match
Broomfield Hospital
The trust should ensure prescription charts are completed with women’s weight and allergy status.
Matched on
terms: chart
CQC action
53match
Poole Hospital
Ensure staff recognise medicine errors and include omitted doses. All medicine errors must be recognised, reported, investigated, monitored and discussed fully.
Matched on
terms: error
CQC action
53match
Newham University Hospital
The services should ensure all drug charts checked by the pharmacist team are clearly documented and audited.
Matched on
terms: chart
PFD report
49match
Redmond Johnson
The coroner identified gaps in gathering medical history, managing complex medications, documenting test results, and assessing detainees' fitness for transfer, including ensuring sufficient notice for these assessments prior to transfer to court.
Matched on
classifier match
PFD report
49match
Ralph Goslin
A junior doctor did not recognise a sub-therapeutic sodium valproate level due to an unclear reference range, which delayed the recognition that the patient was not taking their anti-epilepsy medication.
Matched on
classifier match
PFD report
49match
Philip Allen
The coroner noted that specialist advice was not followed and a medication the patient had stopped was repeatedly prescribed. Concerns were raised about the system at Eltham Palace Surgery that allowed this to occur, and the lack of clarity on whether improvements have been made.
Matched on
classifier match