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
65match
Marjorie Ellery
The coroner raised concerns regarding the administration of medication to patients with known allergies without appropriate senior medical advice, and the need to ensure informed consent in such situations.
Matched on
terms: medication
PFD report
63match
Dominic Philip
The coroner raises concerns about the absence of pre-screening for contrast medium allergies in patients who have not previously had it, and the unexplained presence of Lidocaine in the deceased's system despite a known allergy and no documented administration.
Matched on
classifier match
PFD report
61match
Alan Peck
A patient's prescribed medication was not delivered due to an unconnected syringe driver on a surgical ward, and the device was then not transferred with him to hospice, interrupting his essential pain relief.
Matched on
terms: medication
PFD report
61match
Annette Charlton
The coroner noted that manufacturers producing medications in almost identical packaging may contribute to dispensing errors and potentially to patient deaths.
Matched on
terms: medication
PFD report
61match
Marie Millward-Winter
The coroner noted concerns regarding ambulance technicians administering anticoagulation medication (Apixaban) to Mrs Millward Winter after a head injury. This administration worsened an internal bleed and contributed to her death.
Matched on
terms: medication
PFD report
61match
KennethDaly
The consultant's advice to the GP regarding the continuation of certain pain medications was unclear, and the GP did not seek further guidance. The patient did not receive tailored written advice on his pain relief regimen or the risks of combining multiple opioid medications.
Matched on
terms: medication
PFD report
61match
Ian Hall
The coroner noted it was unclear how Amitriptyline was dispensed instead of Atenolol. Concerns were raised about the lack of clarity regarding pharmacy checks to prevent incorrect medication dispensing, particularly when medication is administered by non-clinically trained carers to vulnerable adults.
Matched on
terms: medication
PFD report
61match
David Martin
The coroner noted inadequate induction for a long-term locum doctor regarding specific cardiology policies. There were also missed opportunities to identify incorrect patient medication, even after the oversight was recognised by staff.
Matched on
terms: medication
PFD report
61match
Susan Young
The coroner noted a lack of clinical handover to the receiving ward and no doctor's instructions for cardiac monitoring. The patient's medication was found in her belongings, allowing an opportunity for further overdose.
Matched on
terms: medication
PFD report
61match
Aaron Atkinson
Concerns were raised about the lack of annual ECGs during GP reviews for individuals prescribed long-term anti-psychotic medication. This appears to stem from a lack of clarity and consistency in national and local guidance regarding the recognised cardiac risks.
Matched on
terms: medication
PFD report
57match
Doris Clark
A doctor prescribed morphine without knowing the dose already given by paramedics. The coroner identified a risk arising from the differing units of measurement for opiate medication used by pre-hospital and hospital services.
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
Michael Anthony
The coroner identified high levels of Gabapentin in a diabetic patient, a drug generally not prescribed to diabetics due to severe reaction risks. Concerns were raised as the GP did not explain the rationale for this prescription.
Matched on
classifier match
PFD report
53match
Elsie Mallalieu
The patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Matched on
classifier match
PFD report
53match
Gabriele Kreichgauer
Concerns were raised about the lack of a final treatment check, resulting in the patient not receiving antibiotics. The coroner also noted a misdiagnosis of an infected cat bite due to an online resource not adequately distinguishing it from cat scratch fever, and the absence of a feedback mechanism within that resource.
Matched on
classifier match
PFD report
53match
Colin Beaumont
The coroner noted concerns regarding the misplacement of a nasogastric tube twice in the same patient, which resulted in pneumothorax and contributed to death.
Matched on
classifier match
PFD report
53match
Jerome Peat
The EMIS computer medical record system did not alert medical staff to a duplicate patient registration, leading to an inadvertent duplication of morphine prescriptions.
Matched on
classifier match
PFD report
53match
Sidra Aliabase
The coroner identified gaps in communication within the paediatric cardiology team and with other hospitals, noting a lack of early planning systems for diagnosing long QT in at-risk newborns. Concerns were also raised about the potential for drug selection errors due to drop-down menu prescribing.
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
GIRFT recommendation
52match
Diabetes
The MDiT should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board which reviews the overall quality of the inpatient service, with support from IT, based on incident reporting, local and national audits of patient harms, diabetes medication errors, length of stay and readmissions.
Matched on
terms: medication
CQC action
52match
St Albans City Hospital
The trust should ensure that patients are weighed to facilitate medication dosing (Regulation 12).
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
Frederick Davidson
The coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Matched on
classifier match
PFD report
49match
Jessica Bond
The coroner noted that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery due to the risk of uterine rupture and associated obstetrical complications.
Matched on
classifier match
PFD report
49match
Lydia Corah
The coroner identified an error where Mrs Corah underwent an X-ray intended for another patient, leading to treatment delay and unnecessary radiation exposure for her, and also adversely affecting the patient for whom the X-ray was originally requested.
Matched on
classifier match
PFD report
49match
Sneh Chaudhry
The coroner noted the similar appearance of Fungizone and Ambisome drug vials, which increases the risk of confusion and potential toxicity. Concerns were also raised regarding nursing checks being passive rather than active.
Matched on
classifier match
PFD report
49match
Lily Girton
The coroner raised concerns about inadequate staffing levels across CAMHS services, specifically noting a shortage of doctors, psychiatrists, and nurses. This resulted in consultant caseloads substantially exceeding recommended levels, posing a risk of future deaths among young people.
Matched on
classifier match
PFD report
49match
Paul Holmes
The coroner noted a lack of clear and detailed handover between doctors during a patient's transfer, an unagreed treatment plan, and insufficient documentation. A prescription error also delayed the administration of hydrating fluids.
Matched on
classifier match
CQC action
48match
North Manchester General Hospital
The trust should ensure that all medications for use in the clinical areas are within the agreed expiry date for safe use.
Matched on
terms: medication
CQC action
48match
Andover War Memorial Hospital
The trust must have clear processes for checking expiration dates, storing medication and recording fridge temperatures.
Matched on
terms: medication
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
CQC action
48match
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: 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