High-risk medication monitoring
Inadequate or absent arrangements for monitoring patients prescribed high-risk medicines, leading to potential harm.
91 items
7 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Mohammed Hussain
The report identifies issues with monitoring clozapine levels, a lack of a safe system to communicate high clozapine levels or effect medication changes, and a lack of understanding of when to measure and how to respond to high clozapine levels; concerns were also raised about pharmacy resourcing and the quality of internal investigations.
Matched on
terms: high, medication, monitoring
CQC action
83match
Charlton House Medical Centre
Arrangements for monitoring patients prescribed high risk medicines continued to place patients at risk of harm.
Matched on
terms: high, monitoring
PFD report
81match
Nathan Cooke
There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Matched on
terms: medication, monitoring
PFD report
77match
Linda Hudson
Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Matched on
terms: high, medication
PFD report
77match
Wayne O’Neill
There was inadequate recognition of drug contraindications and dangerous psychotropic medication combinations, with no routine ECG monitoring performed despite expert recommendations, leading to significant risks.
Matched on
terms: medication, monitoring
PFD report
77match
Sarah Brady
A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.
Matched on
terms: high, medication
PFD report
77match
Malcom Garrett
There was no specific guidance for managing or expediting discharge for immunosuppressed patients at high risk of COVID-19. Discharge was also delayed by opiate toxicity, exacerbated by inadequate kidney function monitoring.
Matched on
terms: high, monitoring
PFD report
77match
Amanda Kramer
A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Matched on
terms: high, medication
PFD report
73match
Stephen Ellis
A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Matched on
terms: high, monitoring
PFD report
73match
Thomas Thurling
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Matched on
terms: medication, monitoring
PFD report
73match
Astonn Mitchell-Male
The Trust lacks a policy for patient medication monitoring and triangulation of information in community settings, compounded by poor and non-existent record keeping, undermining patient safety.
Matched on
terms: medication, monitoring
PFD report
73match
Liane Davenport
There is a need to consider and recommend routine blood level monitoring for patients on long-term, high-dose antipsychotics, especially for older and frailer individuals.
Matched on
terms: high, monitoring
PFD report
73match
Malcolm Garrett
There was no specific guidance for managing or expediting discharge for high-risk immunosuppressed patients susceptible to Covid-19 in hospital. Additionally, insufficient monitoring and understanding of kidney function led to opiate toxicity.
Matched on
terms: high, monitoring
PFD report
69match
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, monitoring
PFD report
69match
Margaret Hions
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Matched on
terms: monitoring
PFD report
69match
Steven Allen
Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Matched on
terms: medication
PFD report
65match
William Bows
The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid tests, and respiratory difficulties.
Matched on
terms: monitoring
PFD report
65match
Amanda Spark
Concerns arose regarding a patient's decision to change her medication regime while under crisis team care, implying potential issues with medication management and oversight.
Matched on
terms: medication
PFD report
65match
Ivan O’Neill
Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.
Matched on
terms: monitoring
PFD report
65match
Evelina Vilkiene
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.
Matched on
terms: medication
PFD report
65match
William Northcott
Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.
Matched on
terms: monitoring
PPO recommendation
64match
Manx Care
Manx Care should ensure that patients who come in with complex and high-risk medication (as per the RCGP guidance) have a medication review when they arrive at the prison.
Matched on
terms: high, medication
PPO recommendation
64match
The Head of Healthcare
The Head of Healthcare should ensure that when high or medium risk medications such as amitriptyline are prescribed, the prescriber ensures that a further in-possession risk assessment takes place in line with local and national policy.
Matched on
terms: high, medication
PFD report
61match
Lucy Kilvert
A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
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
Judith Saville
Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.
Matched on
terms: medication
PFD report
61match
Dorothy Delaney
The concurrent prescription of antiplatelet and anticoagulant medications without specialist advice contradicted national guidelines, significantly increasing haemorrhage risk, especially given the patient's amyloid angiopathy.
Matched on
terms: medication
PFD report
61match
Ann Jacobs
There is a lack of consistent 8-hourly potassium level monitoring and adherence to Trust guidance for patients diagnosed with severe hypokalaemia, posing a risk of adverse cardiac events.
Matched on
terms: monitoring
PFD report
61match
Marjorie Bassendine
Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval prolongation.
Matched on
terms: medication
PFD report
61match
Jamie Poole
It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.
Matched on
terms: medication
PFD report
61match
Bruce Houghton
The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Matched on
terms: medication
PFD report
61match
Teresa Bennett
Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.
Matched on
terms: medication
PFD report
61match
Laura-Jane Seaman
Critical failures in medical record-keeping, delayed patient escalation, non-compliance with major haemorrhage protocols, and misidentification of maternal collapse contributed to the death, highlighting training deficiencies in covert bleeding.
Matched on
terms: high
PFD report
57match
Hireiti Kuflesion
Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.
Matched on
terms: monitoring
PFD report
57match
Chand Ali
Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.
Matched on
terms: monitoring
PFD report
57match
John James
A critical lack of an electronic system to alert medical staff when essential anti-coagulation medication is refused or unadministered, significantly increasing the risk of life-threatening venous thrombo-embolism.
Matched on
terms: medication
PFD report
57match
Jacqueline Green
The hospital failed to adopt national safety recommendations for paracetamol dosage in low-bodyweight patients, leading to overdose risks due to inadequate prescribing alerts, estimated weight entry, and insufficient staff training.
Matched on
classifier match
PPO recommendation
56match
The GP Lead at HMP Exeter
The GP Lead at HMP Exeter should review prescribing processes to ensure high-risk medication assessments are completed in a timely way, with consideration of the impact on the individual
Matched on
terms: high, medication
PHSO casework decision
56match
P-003749 - Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs O raised concerns that the Trust failed to follow blood monitoring and medication guidelines for hypothyroidism during her pregnancy. She says the Trust neglected symptoms and scan assessments that might have signalled a miscarriage risk.
Matched on
terms: medication, monitoring
PPO recommendation
55match
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that the prescribers have a face-to-face conversation with a prisoner if there is an intention to reduce or cease any high risk prescribed medication.
Matched on
terms: high, medication
PFD report
53match
Bridget Cahill
The coroner questions how a patient prescribed morphine can overdose despite receiving less than the prescribed amount, suggesting attention be given to the maximum recommended dose and factors influencing morphine buildup in the body.
Matched on
classifier match
PFD report
53match
Megan Jones
A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Matched on
classifier match
PFD report
53match
Christopher Summerhayes
Complex polypharmacy involving Clozapine led to severe side effects and potential misinterpretation of overdose symptoms, while a possible contraindicating familial lipid disorder was not confirmed.
Matched on
classifier match
PFD report
53match
Ann Coles
A significant gap exists in patient oversight as there is no compulsory requirement for lung imaging when individuals are prescribed long-term amiodarone, despite known lung toxicity risks.
Matched on
classifier match
PFD report
53match
Colin Greenway
Incorrect prescribing by junior doctors, inadequate VTE assessments, and consultants' failure to properly supervise prescribing and ensure continuity of patient care were identified.
Matched on
classifier match
PFD report
53match
Kelly Stevens
A patient on a surgical ward as a medical outlier lacked overall consultant oversight due to absent policy. Doctors failed to monitor electrolytes during IV fluid administration, fluid balance charts were neglected, and outdated care plans were routinely copied and pasted.
Matched on
classifier match
PHSO casework decision
51match
P-003648 - Royal Devon University Healthcare NHS Foundation Trust
Mr A has suffered symptoms of his hypothyroidism and believes he has not had support for the level of monitoring and the medication needed to alleviate those symptoms.
Matched on
terms: medication, monitoring
PFD report
49match
Labhuden Amarshi Vaghadia
A community nurse administered anticoagulant despite patient bleeding, failed to share critical information with other professionals, and demonstrated a lack of professional insight and adequate training.
Matched on
classifier match
PFD report
49match
James Edward Mansfield
Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Matched on
classifier match
PFD report
49match
Christopher Davies
Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
Matched on
classifier match