MAR chart errors
Failures in accurately completing medication administration record (MAR) charts, indicating risks in medication management.
201 items
12 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
78match
Judith Marshall
The pharmacy showed unpoliced drug errors and dispensing mistakes despite checks. Concerns include lack of alert software, mandatory read-back procedures, and a central error database.
Matched on
terms: error, mar
PFD report
77match
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: chart, error
PFD report
77match
Thomas Jordan
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.
Matched on
terms: error, mar
PFD report
74match
Mary Bloom
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.
Matched on
terms: mar
PFD report
70match
Tripta Rani Kumar
A patient with a documented penicillin allergy was prescribed penicillin-containing medication after a critical allergy note was incorrectly overwritten without authorisation, creating a serious risk of anaphylaxis.
Matched on
terms: mar
PFD report
70match
Marie Quinn
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.
Matched on
terms: mar
PFD report
65match
Lee Hollman
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Matched on
terms: mar
PFD report
65match
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: error
PFD report
65match
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: error
PFD report
61match
Kerry Jacobs
The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Matched on
terms: mar
PFD report
61match
Colin Ireland
Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.
Matched on
terms: mar
PFD report
61match
Scott Hooper
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.
Matched on
terms: mar
PFD report
61match
Jennifer Midgley
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.
Matched on
terms: chart
PFD report
61match
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: chart
PFD report
61match
Angela West
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.
Matched on
terms: chart
PFD report
61match
Cuthbert Hingert
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.
Matched on
terms: error
PFD report
61match
Gwyneth Edwards
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.
Matched on
terms: mar
PFD report
61match
Kalma Ram-Henman
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.
Matched on
terms: chart
CQC action
61match
Aspirations (Northampton)
The recording of administration of medicines required improvement. Medicine administration records [MAR] had not been consistently signed or transcribed in line with best practice.
Matched on
terms: mar
CQC action
60match
The Everley Residential Care Home
We recommend that people’s MAR charts are signed by staff after the medication has been witnessed as being taken.
Matched on
terms: chart, mar
PFD report
57match
Robin Brett
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.
Matched on
terms: chart
PFD report
57match
Hayley Clark
Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.
Matched on
classifier match
PFD report
57match
Harold Goulding
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.
Matched on
classifier match
PFD report
57match
Fred Whittaker
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.
Matched on
classifier match
PFD report
57match
Joyce Rumming
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.
Matched on
terms: mar
PFD report
57match
Ahsiyah Bibi
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.
Matched on
terms: error
PFD report
57match
Charlotte Agnew
The report describes failures in the transfer of care, suicide risk assessment, care planning, medication management, and response to a request for urgent assessment; the coroner remains concerned that these failings could recur.
Matched on
classifier match
PFD report
57match
Michalla Sweeting
Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Matched on
classifier match
PFD report
57match
Daphne Penn
Inadequate communication of steroid risks and family concerns, alongside prescribing errors, led to an inadvertent rapid steroid dose reduction without sufficient clinical oversight.
Matched on
terms: error
PFD report
57match
Malcolm Rathmell
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.
Matched on
terms: chart
PFD report
53match
Jill Sinson
The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Matched on
classifier match
PFD report
53match
Jennifer Tompkins
The coroner expressed concern about potential training issues related to the administration of IV medications, and that the stopping of IV vancomycin infusions early may not be routinely documented, raising risks in other cases.
Matched on
classifier match
PFD report
53match
Craig Hamilton
A lack of clear procedures to manage patients routinely obtaining or exceeding prescribed medication dosages, or to discuss alternative pain management, poses significant risks.
Matched on
classifier match
PFD report
53match
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
classifier match
PFD report
53match
Ronald Brewer
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Matched on
classifier match
PFD report
53match
Stephen Coulson
Inadequate systems for controlled drug management and patient observation policies, coupled with a failure to learn from investigations, posed risks to patient safety.
Matched on
classifier match
PFD report
53match
Michael Drewell
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.
Matched on
classifier match
Scottish FAI
51match
Linda Allan
1. Every post-operative patient should be seen by an ANP or a doctor and their presentation recorded in the observation notes on a daily basis. As part of that daily review, the medication prescribed to the patient should be considered and adjusted if appropriate. The observation record should narrate that the medication prescribed has been considered and narrate...
Matched on
terms: chart
PFD report
49match
Redmond Johnson
Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.
Matched on
classifier match
PFD report
49match
Ralph Goslin
An incorrectly presented reference range for sodium valproate levels led a junior doctor to misinterpret a sub-therapeutic result, delaying the recognition of missed medication.
Matched on
classifier match
PFD report
49match
Thomas Farrell
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.
Matched on
classifier match
PFD report
49match
Steven Rogers
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.
Matched on
classifier match
PFD report
49match
George Cheese
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.
Matched on
classifier match
PFD report
49match
Claire Medhurst
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.
Matched on
classifier match
PFD report
49match
Andrew Craig
Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Matched on
classifier match
PFD report
49match
Jacqueline Elliott
Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Matched on
classifier match
PFD report
49match
John Thorp
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.
Matched on
classifier match
CQC action
49match
Tregertha Court Care Home
The provider must ensure that accurate, complete, and contemporaneous records are kept in respect of each service user, specifically regarding the administration of medicines, to confirm that people receive their medicines as prescribed.
Matched on
classifier match
PPO recommendation
49match
The Head of Healthcare
The Head of Healthcare should ensure that when a prisoner does not receive their medication, healthcare staff record the reason on the prisoner’s medications history sheet.
Matched on
classifier match
CQC action
48match
Kingsleigh Residential
We recommend the provider ensures current guidance is followed for handwritten MARs and as required protocols.
Matched on
terms: mar