MAR chart errors
115 items
2 sources
Failures in accurately completing medication administration record (MAR) charts, indicating risks in medication management.
Cross-Source Insight
MAR chart errors has been flagged across 2 independent accountability sources:
1 inquiry rec
114 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (114) — showing 100 most recent
Elise Sebastian
Concerns: Mental health ward staff lacked neurodiversity training and were inexperienced, leading to insufficient staffing, missed patient observations, and incorrect medication charting.
Pending
Urielle Kuyenga
Concerns: A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.
Response: The Trust has appointed an HCC governance lead, updated the standard operating procedure for transfers of care following an audit, and incorporated patient representatives into service meetings. They are also …
Response: The practice has audited Sickle Cell Disease patients, proactively contacts them for annual medication reviews, and clarified prescribing responsibilities with specialists. They have implemented electronic repeat dispensing for these patients, …
Response: The Department has introduced an incentive in the 2025/26 GP contract for identifying patients needing care continuity and implemented "Jess's Rule" (Three Strikes and Rethink) in September 2025 to encourage …
Response: PELC has expanded its policy to require clinicians to review individual records when seeing patients and has shared this learning with staff, including the requirement in staff contracts. They are …
Responded
Paolino Amico
Concerns: Multiple serious medication errors, including non-administration of pain relief and prescription mistakes, occurred. There were also critical failures in the discharge plan for oxygen and delays in escalating a deteriorating patient's condition.
Response: NHS England highlights its ongoing work to improve patient safety, detailing how its Patient Safety Group has strengthened leadership, monitors medicines safety and patient deterioration, and ensures timely incident closure …
Response: The Trust has implemented a new comprehensive discharge checklist for all patients and made medical gases training mandatory for staff. They have also introduced a mandatory 'Essential Training' module for …
Responded
Tracey Oldfield
Concerns: Delayed prescription of usual medications for late-admitted patients leads to inappropriate alternative pain relief. The process for timely medication prescription for such patients is unclear and unresolved.
Response: Royal Cornwall Hospital has established a multidisciplinary group to strengthen governance for timely prescribing of medications for unexpectedly admitted day-case patients. They have identified four workstreams, including ensuring systems alert …
Responded
Alan Mitchell
Concerns: A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.
Response: Optum disputes the factual accuracy of the concern, clarifying that their EMIS Web system does not automatically remove repeat prescriptions after 12 months without GP notification. They explain the system …
Responded
Danielle Jones
Concerns: The GP repeatedly prescribed large amounts of medication, including substances used in overdose, without adequate review, despite the patient self-reporting multiple overdoses and external services raising concerns.
Response: The practice plans to amend its Prescribing Policy by January 2026 to include clear guidance on medication quantities and reducing amounts if there is a self-harm risk. It will also …
Responded
Paula Doreen
Concerns: National risk of concurrent paracetamol prescriptions due to prescribing system deficiencies and inadequate assessment of patient confusion. Inconsistent management of therapeutic excess persists, and new systems risk losing safety nets.
Response: NHS England explains that the Cerner system's duplicate checking functionality was available but likely not enabled and defers to the Royal College of Physicians for national ACVPU assessment training. NHS …
Response: The MHRA outlines existing Human Medicines Regulations 2012 regarding the labelling and warnings for paracetamol medicines and its role in monitoring medicine safety. The MHRA has liaised with NHS England, …
Response: The Royal Pharmaceutical Society (RPS) notes the concerns, clarifying its non-regulatory role and stating that most electronic prescribing systems have duplication alerts, though these often require national oversight to improve. …
Response: Lewisham and Greenwich NHS Trust's electronic prescribing system includes 'hard stop' alerts for concurrent paracetamol prescriptions and dose range checking, with oral dose range checking slated for an update. The …
Response: Oracle Health disputes any defect or fault in its Millennium software regarding concurrent paracetamol prescriptions, stating the functionality exists but is an optional, client-configurable setting. Oracle Health affirms its system …
Responded
Margaret McNaughton
Concerns: The Trust consistently fails to ensure adequate checking and documentation of patient allergy status, leading to ongoing adverse incidents, as current policies and communications are insufficient to embed these critical safety practices.
Responded
Simon Hockenhull
Concerns: Inconsistent definitions of a 'month' for diabetic medication prescriptions cause supply challenges, leading to inconsistent patient adherence and potential life-threatening health impacts.
Responded
Julie Beasley
Concerns: Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of professional curiosity and poor record-keeping also contributed.
Responded
Jacqueline Green
Concerns: 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.
Responded
Leslie Hurwood
Concerns: Hospital nurses are incorrectly administering insulin after meals, reducing its effectiveness and causing hypoglycaemic episodes, indicating insufficient training adherence and potential staffing impacts on correct medication procedures.
Responded
Vauna Leeming
Concerns: Nurses, including agency staff, consistently failed to document vital anticoagulation and compression stocking administration, indicating insufficient awareness of professional duties and reporting omissions.
Responded
Ava Hodgkinson
Concerns: Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Responded
David Crompton
Concerns: The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
Responded
Mary Whitlock
Concerns: A patient with opioid allergies was given morphine, highlighting a medication error. Concerns also included persistent ward understaffing and the absence of a discharge summary or safety netting advice for a vulnerable patient.
Responded
Amanda Richardson
Concerns: Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.
Overdue
Rachel Gibson
Concerns: Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Responded
Norman Leadbeater
Concerns: Inadequate care plans and missing medication details on the Medication Administration Record (MAR) led to unsafe fluid administration. A critical audit and liaison with GPs remain incomplete months after recommendation.
Responded
Susan Williams
Concerns: The In-Patient Medication Administration Record and A&E Record Card fail to document medication prescription times, only administration. This lack of recorded prescription times hinders checks for timely delivery and cross-referencing.
Responded
Susan Edwards
Concerns: A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.
Responded
Zarah Ravn
Concerns: A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up for deteriorating mental health, created significant safety risks.
Responded
William Stockil
Concerns: The electronic prescription system has a critical flaw: medication end alerts are only visible to prescribers upon accessing patient records, risking missed reviews and unintended cessation of vital medications.
Responded
Eleanor Smith
Concerns: A significant 24-hour delay in antibiotic administration and difficulties with cannula siting raised concerns about the effective delivery of prescribed medication and the accuracy of medical records.
Responded
Jason Brown
Concerns: Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.
Responded
Chloe Tapp
Concerns: An overwhelmed, understaffed neurology department caused delayed referrals, inadequate consultations, medication errors, and unanswered patient queries. This created unsafe backlogs and sub-optimal care, persisting years after the death.
Responded
Kate O’Donnell
Concerns: Multiple failures in surgical planning, medical knowledge regarding prophylactic antibiotics, post-operative vigilance, and communication with family led to critical care oversights and unsafe discharge.
Responded
Sarah Mitchell
Concerns: Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access to her medical records detailing a controlled dispensing regime.
Responded
Mohammed Akram
Concerns: A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Responded
Amirah Khalifa
Concerns: The Shared Care Record system lacks automated flags for long-term steroid monitoring and a field for recording clinical indications, posing risks for unsafe prescribing.
Overdue
John Singleton
Concerns: The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.
Responded
Jason Bayley
Concerns: Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.
Responded
Tracey Rose
Concerns: A patient was discharged home without their anticoagulant prescription, and a hospital dose may have been missed, significantly contributing to a fatal pulmonary embolism.
Responded
John Hoare
Concerns: There was a gross failure in basic medical attention concerning lithium prescribing and dispensing, which resulted in the patient being sectioned and potentially contributed to his death.
Responded
Janet Spencer
Concerns: Critical patient information was inadequately shared between care facilities during hasty transfers, leading to medication errors. The receiving care home also lacked the authority to refuse referrals despite insufficient information.
Responded
Alison Ross
Concerns: There is no clear guidance for monitoring patients who self-administer medications but do not take them at the time of dispensing, posing a risk to medication adherence.
Responded
Audrey King
Concerns: Inconsistent record-keeping, a faulty process for cross-referencing digital and handwritten notes, and a lack of alerts for reviewing suspended medications pose significant risks in patient care.
Responded
Juanita Nti
Concerns: Unclear morphine prescription details and an EMIS system lacking correct drug strengths led to a GP and pharmacist dispensing an incorrect, higher dose, resulting in a child's fatal overdose.
Responded
Marie Zarins
Concerns: Flawed Multi-Disciplinary Team meetings and an inadequate serious incident investigation led to a mental health patient not receiving prescribed anti-depressants or sleeping tablets due to incorrect medication understanding and poor record review.
Responded
John James
Concerns: 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.
Responded
Matthew Power
Concerns: The EMIS prescribing system has flaws, including repeat prescriptions remaining 'pending' after cancellation, confusing grouping of dosages, and difficulty in accurately auditing prescribing history, posing a risk of medication errors.
Responded
Jessica Hodgkinson
Concerns: Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.
Overdue
Julie Hancock
Concerns: Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about wider patient safety.
Responded
Bency Joseph
Concerns: There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.
Responded
John Roberts
Concerns: A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel perforation risk for diverticular disease patients.
Responded
Lewis Begley
Concerns: The mental health hospital lacked a proper record of stored medication, especially drugs subject to misuse, and had no system to track patient access or provide fixed overdose treatment training for doctors.
Responded
Donald Compton
Concerns: Multiple prescribing and dispensing errors occurred due to an electronic prescribing tool that allowed bypassing allergy checks and a lack of specific knowledge about constituent drugs among prescribers and pharmacists.
Overdue
Saif Hussain
Concerns: The trust lacked a single, integrated system for drug record-keeping and monitoring, with insufficient limits on administration and inadequate implementation of safety software like Guardrails.
Responded
Christopher Collinson
Concerns: A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.
Responded
Darren Lawrence
Concerns: Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.
Responded
Vivien Brunning
Concerns: Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Overdue
Shyama Rampadaruth
Concerns: A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.
Responded
Wendy Wilkes
Concerns: The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.
Responded
Jennifer McKoy
Concerns: An inadequate audit process for sample monitoring and a lack of clear protocol for managing anticoagulation/prophylaxis regimes in community patients posed significant risks.
Responded
Gareth Warburton
Concerns: Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
Overdue
David Potts
Concerns: Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
Overdue
Annie Lloyd
Concerns: Inadequate processes for checking warfarin dosage resulted in GPs prescribing medication based on copied records and relying on family input, without direct verification of the correct dosage.
Overdue
Mark Jarvis
Concerns: The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Overdue
Robert Rostron
Concerns: Critical over-reliance on inadequately inducted agency nurses as senior staff led to unfamiliarity with essential policies, records, and patient care plans, resulting in medication errors.
Responded
Karanbir Cheema
Concerns: Systemic failures in allergy management included poor understanding by pupils and staff, unchecked medication, non-standardised action plans, and inadequate awareness of critical EpiPen administration protocols.
Responded
Terence Bradfield
Concerns: Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.
Overdue
John Thorp
Concerns: Inconsistent prescription practices for TED stockings, coupled with inadequate documentation for nursing administration, increased the risk of thromboembolic formation due to stockings potentially not being given as prescribed.
Responded
Malcolm Rathmell
Concerns: Incorrect warfarin prescribing went unidentified by multiple professionals, an anti-coagulation chart was mislabeled, and a lack of ward-based pharmacy review, with proposed actions still in infancy.
Responded
Gwyneth Edwards
Concerns: Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Overdue
Jacqueline Elliott
Concerns: Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Responded
Kalma Ram-Henman
Concerns: Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.
Responded
Michael Drewell
Concerns: A senior clinician's critical medication advice was not followed by a junior doctor, as it wasn't on electronic notes, highlighting a dangerous reliance on digital records over handwritten instructions.
Responded
Cuthbert Hingert
Concerns: Significant medication errors, including duplicate prescribing and incorrect dosages, occurred due to clinicians failing to check databases and insufficient training. A nurse also failed to report these errors according to protocol.
Overdue
Daphne Penn
Concerns: Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Overdue
Angela West
Concerns: High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.
Responded
Andrew Craig
Concerns: Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Responded
Michalla Sweeting
Concerns: Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Overdue
James Quinton
Concerns: 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.
Responded
Paul Mullen
Concerns: The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner organisations further hinders communication.
Overdue
Stephen Coulson
Concerns: Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Overdue
Ronald Brewer
Concerns: Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Responded
Jennifer Midgley
Concerns: The drug administration chart fails to clearly distinguish between oral and intravenous paracetamol, lacks patient weight reference for IV dosage, and omits a reminder for weight-modified administration.
Overdue
Claire Medhurst
Concerns: The discharge process lacked crucial cautionary advice on medication use, and treating clinicians failed to receive alerts for abnormal liver function and toxic paracetamol levels.
Responded
Hayley Sheehan
Concerns: 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.
Responded
Songul Bozdag
Concerns: 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.
Responded
Craig Hamilton
Concerns: A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Responded
George Cheese
Concerns: A patient with known suicidal thoughts was prescribed a large quantity of antidepressant medication. There was no system or "flag" in their notes to limit repeat prescriptions in such circumstances.
Responded
Joyce Rumming
Concerns: Poor communication between software packages meant an allergic marker for Amoxicillin was missed, leading to the patient being administered a drug they were allergic to.
Responded
Nasar Ahmed
Concerns: A school nurse's inadequate medication review process included using an incorrect allergy action plan, not verifying medication in school, and failing to ensure updated, in-date medication.
Responded
Ahsiyah Bibi
Concerns: Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.
Overdue
Charlotte Agnew
Concerns: Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment delays.
Overdue
Scott Hooper
Concerns: Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.
Overdue
Thomas Jordan
Concerns: Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Overdue
Fred Whittaker
Concerns: A patient was erroneously re-prescribed medication due to the lack of a system for recording reasons for stopping drugs and poor prescription management, a risk potentially widespread in GP practices.
Overdue
Harold Goulding
Concerns: Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Responded
Terence Stilges
Concerns: Repeated incorrect labelling of troponin blood samples resulted in unavailable critical diagnostic information, contributing to delayed diagnosis and patient discharge before subsequent readmission with an acute myocardial infarction.
Overdue
Peter Rowe
Concerns: A patient with severe memory loss was prescribed penicillin despite a documented allergy, which was later deleted. Allergy information was accepted uncritically from the patient and an uninformed spouse.
Overdue
Hayley Clark
Concerns: Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Responded
Betty Addison
Concerns: A patient at a care home received five additional, unprescribed Dalteparin injections, with no clear explanation for their source or why they were administered.
Overdue
Steven Rogers
Concerns: A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
Responded
Robin Brett
Concerns: A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Overdue
Marie Quinn
Concerns: Sub-optimal DVT prophylaxis, including delayed medication and missing mechanical treatment, was provided. Incorrect discharge instructions led to early cessation, and the nursing home failed to query excess medication.
Overdue
Mary Bloom
Concerns: Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight patients was also easily missed due to poor visibility on posters.
Responded
Thomas Farrell
Concerns: The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
Overdue
Lottie Reid
Concerns: 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.
Responded