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
The coroner noted ongoing risks from unsafe prescribing of controlled drugs by Ivy Grove Surgery and a limited understanding of reporting serious prescribing incidents. Concerns were also raised about poorly coordinated management and prescribing for neurological patients under shared care.
Matched on
terms: management, unsafe
PFD report
73match
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
terms: medication
PFD report
73match
Joan Osborne
Concerns included the nursing home's failure to seek specialist diabetes and dementia outreach assistance, adequately manage Mrs Osborne's insulin refusal, or recognise her deteriorating condition. Inadequate record keeping and incorrect medication administration were also noted.
Matched on
terms: medication
GIRFT recommendation
73match
Anaesthesia and Perioperative Medicine
Develop and implement perioperative pathways and protocols for managing pain medication. a Follow the Royal College of Anaesthetists (RCoA) 'Opioids Aware' guidance on pain management and ensure both staff and patients are educated as to the risks and signs of opioid addiction. b Ensure that preoperative initiation of a pain management pathway is followed for all patients. (In...
Matched on
terms: management, medication
CQC enforcement action
71match
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission (CQC) has told Mid Essex Hospital Services NHS Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection at Broomfield Hospital in Chelmsford, Essex, which found the trust was not meeting national standards relating to the care and welfare of people who use services...
Matched on
terms: management
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
CQC action
69match
Worthing Hospital
The trust must ensure the proper and safe management of medicine including prescribing systems.
Matched on
terms: management
CQC enforcement action
69match
Urgent Enforcement Action: Birmingham and Solihull Mental Health NHS Foundation Trust
The Care Quality Commission imposed urgent conditions on the registration of Birmingham and Solihull Mental Health NHS Foundation Trust following focused inspections. Inspectors found several concerns, including ligature risks across services and unsafe storage and transport of medicines. The conditions require the trust to address all ligature risks by 18 June 2021 and implement an effective system to...
Matched on
terms: unsafe
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
Edward Devlin
The coroner identified a practice where nurses reportedly slide medication, including controlled drugs, under cell doors rather than directly handing it to patients. This raises concerns about whether patients receive their medication, the accuracy of drug records, and the potential for drug misuse or trading within the establishment.
Matched on
terms: medication
PFD report
65match
Andrew Aitken
Concerns included inadequate handling of medication, failure to obtain historical psychiatric records for a patient without a GP, and discharge deficiencies such as lacking direct mental health referral and appropriate clothing.
Matched on
terms: medication
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
CQC action
65match
West Cumberland Hospital
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
CQC action
65match
Sunderland Royal Hospital
The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.
Matched on
terms: medication
CQC action
65match
South Tyneside District Hospital
The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.
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
The coroner noted that Hope House lacked a clear and accessible policy or protocol regarding the administration and holding of medication by staff, which was not made known to prescribers or other relevant personnel.
Matched on
terms: medication
PFD report
61match
Derrick Rivers
The coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Matched on
terms: management
PFD report
61match
Peter Brookes
Concerns were raised about the hospital administration of PD medication not following patient regimens, the unavailability of doctors for non-emergency weekend reviews, and the unelucidated cause of a dispensing error involving incorrect medication.
Matched on
terms: medication
PFD report
61match
Iris Grimwood
The coroner identified difficulties in providing adequate nursing care, including errors in temperature measurement and incorrect medication application. These issues were attributed to insufficient nursing staff levels, recruitment challenges, and training funding problems.
Matched on
terms: medication
PFD report
61match
Darren Linfoot
The coroner noted that non-controlled drugs, including opiates, are not audited, posing a risk of potent medication being unaccounted for. There was also a lack of consistent understanding and methods among nursing staff for performing regular patient observations.
Matched on
terms: medication
PFD report
61match
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
terms: medication
PFD report
61match
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
terms: medication
PFD report
61match
Ronald Brewer
Concerns were raised regarding the administration of medications, with particular note on the documentation and dispensation of palliative medications.
Matched on
terms: medication
PFD report
61match
Percy Jacks
The coroner identified inadequate communication between hospital, GP, and care home, including misdirection of scan results. Concerns also noted the GP surgery's poor system for reviewing prescribed medication dosage and duration.
Matched on
terms: medication
PFD report
61match
Russell Robb
The coroner identified a lack of regular medication reviews and no guidelines to limit medication availability. Additionally, limited information sharing within the Trafford Adult Safeguarding Board hindered awareness of police interactions with Mr Robb and restricted strategic oversight.
Matched on
terms: medication
PFD report
61match
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: medication
CQC action
61match
Nottingham City Hospital
The trust must follow appropriate guidance in the proper and safe storage and administration of medicines, including ensuring fridge temperatures are monitored, recorded and out of range temperatures escalated in line with trust requirements.
Matched on
classifier match
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
GIRFT recommendation
61match
Renal Medicine
Ensure renal centres and ICSs deliver effective medicines optimisation in order to improve the safe care of patients with kidney disease and increase healthcare value. a) Renal centres and ICSs to increase the number and scope of work of the renal pharmacy workforce, guided by the recommendations of the pharmacy section of the BRS workforce report. b) Advanced...
Matched on
terms: medication
CQC action
61match
Westmorland General Hospital
The trust should ensure that the uptake of medicines management e-learning be prioritised to help improve medicines safety.
Matched on
terms: management
CQC action
61match
Wavertree Bungalow
The provider must ensure there is a system in place for the safe management of people's medicines.
Matched on
terms: management
CQC action
61match
The York Hospital
The service must ensure all patients in ED are wearing wristbands at all times for improved safeguarding, security and easier identification when prescribing and administering medications.
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
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
Harold Elvidge
The coroner noted inconsistent availability of Omnicell cabinets across the trust and raised concerns about the risk of different fluid types being mixed up in non-critical care settings. A trust-wide review of policies for safe fluid storage, including packaging and labelling, was suggested.
Matched on
classifier match
PFD report
57match
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: medication
PFD report
57match
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
57match
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
terms: medication