Unsafe medication management
Failures in the safe management of medicines, including storage, administration, record-keeping, prescribing, and disposal.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
81match
Electronic prescribing and medicines administration systems and safe discharge
The practice of documenting only newly prescribed medication on discharge summaries should be reviewed from a patient safety and medicines management perspective.
Matched on
terms: management, medication
HSSIB recommendation
80match
Medication not given: discharge from an acute hospital to the community
How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets which detailed injection technique and what to do in the event of illness, and type 2 diabetes and healthy eating booklets were also provided. 2.3 The patient was advised that the diabetes specialist nursing team would follow up during the...
Matched on
terms: medication
Committee recommendation
78match
#24 - Commission independent review into hospital medicines management, focusing on automation and digital systems.
We recommend that an independent review is commissioned to explore hospital medicines management, to report within one year. The review should make recommendations, particularly around how the potential of automation and technological systems like connected medication management could be realised and how learning from Global Digital Exemplars can be built upon in Trusts across England. (Paragraph 131) Pharmacy...
Matched on
terms: management, medication
PFD report
77match
Kymberley Holden
Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Matched on
terms: management, unsafe
PFD report
73match
Andrew Aitken
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Matched on
terms: management, medication
PFD report
73match
Percy Jacks
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Matched on
terms: management, medication
PFD report
73match
Sandra Miller
Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Matched on
terms: management, unsafe
HSSIB recommendation
70match
Medication not given: administration of time critical medication in the emergency department
Who in your patient pathway is responsible for prescribing time critical medications?
Matched on
terms: medication
PFD report
69match
Beatrice Gatt
A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Matched on
terms: management, medication
PFD report
69match
Jonathan Earp
Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Matched on
terms: management, medication
CQC action
69match
Worthing Hospital
The trust must ensure the proper and safe management of medicine including prescribing systems.
Matched on
terms: management
HSSIB recommendation
66match
Medication not given: anticoagulation before and after a procedure
How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
Matched on
terms: medication
PFD report
65match
Harold Elvidge
A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
Matched on
terms: management
PFD report
65match
Edward Devlin
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Matched on
terms: medication
PFD report
65match
Songul Bozdag
The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Matched on
terms: medication
PFD report
65match
Hayley Sheehan
The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.
Matched on
terms: unsafe
HSSIB recommendation
65match
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital
Clinical pharmacy services should consider using validated tools to assist in prioritising pharmacy care and identifying high-risk medicines and high-risk situations for medication error. Where electronic medical record systems are used, such tools could be integrated into these systems to aid prioritisation.
Matched on
terms: medication
PPO recommendation
64match
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession medication that has not been collected.
Matched on
terms: management, medication
IMB annual report
64match
North East Midlands, Yorkshire & Humber STHF (2023)
This is the first annual report for the North East Midlands, Yorkshire & Humberside IMB, covering Short-Term Holding Facilities (STHFs) from February 2022 to January 2023. While staff conduct and detainee treatment generally received positive feedback, significant concerns arose regarding the unsafe opening and managing large intakes at Swinderby Residential STHF. The Board also highlighted the critical and...
Matched on
terms: medication, unsafe
IMB annual report
64match
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Scotland and Northern Ireland STHF IMB report highlights generally humane treatment by staff but identifies significant concerns across multiple facilities for the period February 2022 to January 2023. Key issues include the unsafe removal of prescription medication, inadequate disability provisions, and the unsuitability of airport holding rooms for increasingly prolonged detentions. The Board also notes long-overdue building...
Matched on
terms: medication, unsafe
IMB recommendation
64match
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
64match
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: management, medication
Inquiry recommendation
62match
R8 - Medication audit and NICE compliance
Medication should never be used simply to subdue people in the absence of other forms of treatment and good quality care. DoH should issue a regional audit pro forma to measure compliance with National Institute for Health and Care Excellence (NICE) guidelines and Trusts should conduct quarterly audits. These audits should be part of an RQIA review as...
Matched on
terms: medication
Committee recommendation
62match
#168 - Implement new secure systems for distributing and administering prison medication to prevent diversion.
HMPPS should conduct an urgent review of all prescription medication dispensing procedures within prisons to identify and close loopholes exploited for diversion and introduce enhanced supervision of medication queries. New secure systems for distributing and administering medication must be implemented immediately to prevent diversion and protect vulnerable prisoners. (Recommendation, Paragraph 39) Drivers of the demand and impact of...
Matched on
terms: medication
PFD report
61match
Richard White
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Matched on
terms: medication
PFD report
61match
Derrick Rivers
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Matched on
terms: management
PFD report
61match
Peter Brookes
Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Matched on
terms: medication
PFD report
61match
Iris Grimwood
Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
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
Philip Allen
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Matched on
terms: medication
PFD report
61match
Moses McDonald
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Matched on
terms: medication
PFD report
61match
Lottie Reid
There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Matched on
terms: medication
PFD report
61match
Geoffrey Parry
Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Matched on
terms: management
PFD report
61match
Lyndsey Holt
Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Matched on
terms: unsafe
PFD report
61match
Ronald Brewer
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Matched on
terms: medication
PFD report
61match
Russell Robb
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Matched on
terms: medication
HSSIB recommendation
61match
Insulin: supporting safe self-administration for patients in the community with a disability
Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances?
Matched on
terms: medication
CQC action
61match
The County Hospital
The service should improve the safe and proper management of medicines are stored safely and appropriately.
Matched on
terms: management
CQC action
61match
Montagu Hospital, Mexborough
Thetrustmustensuretheproperandsafemanagementofmedicines.Regulation12(2)(g)
Matched on
terms: management
IMB recommendation
61match
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
Matched on
terms: management
Committee recommendation
61match
#23 - Strategic oversight lacking for widespread adoption of automation in hospital medicines management.
There are clearly benefits to be found from using automation and technology particularly within hospital medicines management. These benefits could unlock gains in productivity, improve patient safety and free up pharmacist time to work more directly with patients. There are pockets of excellent practice across the NHS, but, outside of formal programmes like the Global Digital Exemplar programme,...
Matched on
terms: management
IMB annual report
59match
Thameside (2021)
HMP Thameside operated under a Covid-19 lockdown regime for much of the reporting year, successfully containing the virus but impacting prisoner welfare. The prison transitioned to a restricted regime, and introduced proactive safety management initiatives, including a revised approach to gangs. However, key concerns persist regarding the long-term effects of confinement, delays in mental health transfers, staffing shortages,...
Matched on
terms: management, medication
PFD report
57match
Afifa Qaisar
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Matched on
classifier match
PFD report
57match
Leonardus Vries
Significant documentary failings and lack of audit for non-controlled medication created opportunities for abuse or theft, highlighting a need for improved internal control measures.
Matched on
terms: medication
PFD report
57match
Laurence Boyens
Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Matched on
terms: medication
PFD report
57match
Isaac Bahar
A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Matched on
terms: medication
PFD report
57match
Maureen Chatterley
Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Matched on
terms: medication
PFD report
57match
Steven Fone
The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.
Matched on
terms: medication
PFD report
57match
Christopher Roberts
Care plan reviews lacked documentation, making it impossible to confirm outcomes or whether previous suicide attempts were considered. Additionally, Nomad trays might be unsuitable for certain patients, impeding medication benefits.
Matched on
terms: medication
PFD report
57match
James Quinton
Poor nursing documentation and observation charts hindered clinical oversight. A critical medication was incorrectly administered due to a verbal prescription, highlighting a lack of essential checking procedures.
Matched on
terms: medication