Medication Contamination/Misadministration
Unexplained presence of an allergic medication in a patient's system, raising concerns about contamination or misadministration.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Dominic Philip
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Matched on
terms: contamination, medication
PFD report
65match
Lily Girton
Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Matched on
terms: medication
PFD report
65match
Aaron Atkinson
There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Matched on
terms: medication
PFD report
61match
Alan Peck
Critical medication was not delivered due to an unconnected syringe driver and its subsequent failure to be transferred with the patient, depriving him of essential drugs during transport.
Matched on
terms: medication
PFD report
61match
Marjorie Ellery
Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Matched on
terms: medication
PFD report
61match
Annette Charlton
Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.
Matched on
terms: medication
PFD report
61match
Jerome Peat
A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Matched on
terms: medication
PFD report
61match
Susan Young
Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
Matched on
terms: medication
PFD report
57match
Sneh Chaudhry
Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Matched on
terms: medication
PFD report
57match
Marie Millward-Winter
Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Matched on
terms: medication
PFD report
57match
Ian Hall
Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Matched on
terms: medication
PFD report
57match
John Skinner
A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Matched on
terms: medication
PFD report
57match
David Martin
A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Matched on
terms: medication
PFD report
57match
Sidra Aliabase
Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.
Matched on
terms: medication
HSSIB recommendation
57match
The use of an appropriate flush fluid with arterial lines
HSIB recommends that the Department of Health and Social Care, once post-market surveillance data is available, involves relevant stakeholders including the Association of Anaesthetists’ review and determine appropriate actions that could be taken to further mitigate the risk of blood sample contamination by the flush fluid when using arterial transducer line systems.
Matched on
terms: contamination
IMB recommendation
57match
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective...
Matched on
terms: medication
LGO / SPSO decision
56match
PSOW-202101243 - Cardiff and Vale University Health Board
Mr X complained that the Health Board had failed to prescribe him a newly approved medication called Fampridine, a drug used to improve walking ability in patients with multiple sclerosis. Mr X said this resulted in him paying for private prescriptions when he should have received the treatment from the NHS. The Ombudsman found that the Health Board...
Matched on
terms: medication
PFD report
53match
Frederick Davidson
Inadequate note-keeping, inappropriate use of a nasogastric tube given the patient's history, unexplained gaps in clinical notes, communication breakdown between junior doctor and consultant, lack of pneumothorax recognition, premature authorisation of feeding, and delays in X-ray reporting were highlighted.
Matched on
classifier match
HSSIB recommendation
53match
Unintentional overdose of morphine sulfate oral solution
It may be beneficial if manufacturers of morphine oral solution 10mg in 5ml ensure that any dose measurement aid, if supplied with the medication, is able to measure a full range of possible doses. The intention of this safety observation is to ensure that professional bodies and regulators highlight the importance to their membership of participating in HSIB...
Matched on
terms: medication
IMB recommendation
52match
Berwyn (2020)
Inpatient units/Medication Policy
Matched on
terms: medication
IMB recommendation
52match
North West and Midlands STHF (2023)
For the fifth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
LGO / SPSO decision
52match
PSOW-202005941 - Cwm Taf Morgannwg University Health Board
Mrs A complained that a GP Practice in the area of Cwm Taf Morgannwg University Health Board failed to arrange a timely referral to secondary care for her late mother, Mrs G, between 20 January and 18 March 2020 in relation to increasingly painful symptoms in her lower left leg. Mrs A was later admitted to hospital on...
Matched on
terms: medication
PFD report
49match
Jessica Bond
Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Matched on
classifier match
PFD report
49match
Lydia Corah
An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Matched on
classifier match
PFD report
49match
Gabriele Kreichgauer
The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Matched on
classifier match
PFD report
49match
KennethDaly
Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
Matched on
classifier match
PFD report
49match
Doris Clark
A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Matched on
classifier match
PFD report
49match
Colin Beaumont
A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Matched on
classifier match
PFD report
49match
Michele Duckworth
The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.
Matched on
classifier match
IMB recommendation
48match
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That the administration of detainees’ personal prescribed medication in airport HRs be resolved forthwith.
Matched on
terms: medication
IMB recommendation
48match
Bedford (2021)
There are issues around the dispensing of medication that need resolving. Some prisoners are not receiving their medication, while others may be selling it on, as there has been inadequate supervision at the pharmacy.
Matched on
terms: medication
IMB recommendation
48match
Hollesley Bay (2023)
A review of the arrangements for dispensing medication is requested. The current regime is slow and cumbersome, which causes frustration for prisoners and friction with healthcare staff.
Matched on
terms: medication
IMB recommendation
48match
Forest Bank (2024)
The Board has received complaints about medication treatment dispensing times being missed frequently, which has an impact on prisoners’ health. What action will the prison take to improve this outcome?
Matched on
terms: medication
PHSO casework decision
48match
P-004653 - United Lincolnshire Teaching Hospitals NHS Trust
The Trust failed to provide her father's lupus medication, unsafely discharged him, and delayed its complaint response due to lost medical records, causing distress and worsening his condition.
Matched on
terms: medication
PHSO casework decision
48match
P-001695 - The Dudley Group NHS Foundation Trust
Miss I complained about incorrect medication, delayed antibiotics, not allowing a relative to attend tests, problems during a swallowing test, and failure to perform a post-mortem on her grandmother.
Matched on
terms: medication
PHSO casework decision
48match
P-001620 - University Hospitals of North Midlands NHS Trust
Mrs A complained about inappropriate medication, inappropriate administration of antibiotics, and delays in antibiotics for her mother's end-of-life care, causing a horrific death.
Matched on
terms: medication
PHSO casework decision
48match
P-003448 - East Sussex Healthcare NHS Trust
Miss B and Mrs B complained a nurse administered wrong medication, and the Trust delayed notifying the family of Mr B's deterioration, causing distress and affecting their grieving process.
Matched on
terms: medication
IMB recommendation
48match
North and Midlands Short Term Holding Facilities (2022)
For the fourth year in succession, the Board repeats its concern at the lack of proper procedures which would allow DCOs or other qualified personnel to provide detained individuals with access to their prescribed medication. The Board continues to note that the welfare of detained individuals has been adversely affected by this situation. This occurs particularly in holding...
Matched on
terms: medication
IMB recommendation
48match
Wandsworth (2023)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Matched on
terms: medication
IMB recommendation
48match
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
Matched on
terms: medication
IMB recommendation
48match
Wandsworth (2024)
Non delivery of medications has been a major concern to the Board this year. What is being done to ensure that this improves?
Matched on
terms: medication
PHSO casework decision
48match
P-001385 - Lewisham and Greenwich NHS Trust
Ms E complained the Trust gave her incorrect treatment, documented incorrect medication information, lost ECG reports, and failed to respond to her further concerns, causing her and her daughter PTSD.
Matched on
terms: medication
PHSO casework decision
48match
P-003706 - Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr L complained the Trust left him without essential eye drops for eight weeks due to errors and failed to advise him on stopping medication as an inpatient, causing stress.
Matched on
terms: medication
LGO / SPSO decision
47match
PSOW-202504068 - Swansea Bay University Health Board
Miss A complained that the Health Board prescribed and administered the incorrect dose of epilepsy medication to her 3-year old daughter when she attended the Emergency Department. Miss A said that despite having evidence of the prescribed medication, the Health Board said that there was no record of a prescription being given to her daughter. Miss A said...
Matched on
terms: medication
PFD report
45match
Norma Sheppard
The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Matched on
classifier match
PFD report
45match
Michael Anthony
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Matched on
classifier match
PFD report
45match
Elsie Mallalieu
Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Matched on
classifier match
PFD report
45match
Ashley Walker
A communication error confused ingestion with a spillage, and an effective antidote (methylene blue) for toxicity was not available on the ambulance.
Matched on
classifier match
PFD report
45match
Anita Graves
The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
Matched on
classifier match
PFD report
45match
Rachel Edwards
The report notes Rachel was informally admitted.
Matched on
classifier match