Medication Contamination/Misadministration
30 items
2 sources
Unexplained presence of an allergic medication in a patient's system, raising concerns about contamination or misadministration.
Cross-Source Insight
Medication Contamination/Misadministration has been flagged across 2 independent accountability sources:
1 inquiry rec
29 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (29)
Sidra Aliabase
Concerns: Failures included not expediting Long QT Syndrome diagnosis, inadequate communication of expert opinion, a five-fold medication overdose, and a significant delay in recognizing and treating subsequent hypocalcaemia.
Overdue
Aaron Atkinson
Concerns: There is a concern that specialist services may not consistently retain responsibility for, or adequately monitor, the physical health of patients for at least 12 months after initiating antipsychotic medication.
Responded
Susan Young
Concerns: Critical failures included no clinical handover, missing doctor's instructions for cardiac monitoring, and the patient retaining personal medication, creating a risk of further overdose.
Responded
David Martin
Concerns: A locum doctor lacked cardiology induction and policy awareness, and there were multiple failures to identify incorrect medication, even after a senior nurse recognised the oversight.
Responded
Paul Holmes
Concerns: Poor communication, lack of direct doctor-to-doctor handover, and unrecorded treatment plans during hospital transfer led to delayed administration of crucial intravenous fluids.
Overdue
Anita Graves
Concerns: The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
Responded
Lily Girton
Concerns: Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Overdue
John Skinner
Concerns: A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Overdue
Ian Hall
Concerns: Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Overdue
Michele Duckworth
Concerns: The patient was incorrectly prescribed Tazocin, an antibiotic against trust guidelines due to prior ESBL colonization, an error that was repeatedly missed during medical reviews.
Overdue
Jerome Peat
Concerns: A computer system failure at the GP surgery led to duplicated morphine prescriptions, causing the deceased to receive significantly more medication than intended and resulting in an overdose.
Overdue
Ashley Walker
Concerns: A communication error confused ingestion with spillage, and the effective antidote for toxicity was dangerously unavailable on the ambulance.
Responded
Doris Clark
Concerns: A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Overdue
Colin Beaumont
Concerns: A nasogastric tube was misplaced twice in the same patient, resulting in a pneumothorax that directly contributed to their death.
Responded
KennethDaly
Concerns: Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
Overdue
Gabriele Kreichgauer
Concerns: The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Overdue
Marie Millward-Winter
Concerns: Administration of anticoagulation medication after a head injury, advised by ambulance technicians, likely worsened an internal bleed and contributed to death.
Responded
Sneh Chaudhry
Concerns: Drug confusion due to similar vial appearance between Fungizone and Ambisone, combined with passive nursing checks, created a risk of administering the wrong, more toxic medication.
Overdue
Rachel Edwards
Concerns: The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding systemic failures or future death risks.
Responded
Lydia Corah
Concerns: An error led to a patient undergoing an X-ray intended for another, causing delay in assessment, unnecessary radiation, and adversely affecting the intended patient.
Responded
Annette Charlton
Concerns: Pharmaceutical manufacturers are producing medications in almost identical packaging, which significantly increases the risk of dispensing errors and poses a serious threat to patient safety.
Overdue
Marjorie Ellery
Concerns: Medication was administered to a patient with a known allergy without appropriate senior medical advice, and the consent obtained for this treatment was not informed consent.
Responded
Elsie Mallalieu
Concerns: Inappropriate ward placement with untrained staff and inadequate nursing notes led to missed observations and an incorrect DNAR decision, hindering escalation for treatable infection.
Responded
Alan Peck
Concerns: 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.
Overdue
Jessica Bond
Concerns: Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
Overdue
Michael Anthony
Concerns: The deceased had dangerously high Gabapentin levels, a drug usually avoided in diabetics due to severe reaction risks, with no clear rationale from the GP for its prescription.
Overdue
Norma Sheppard
Concerns: Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.
Overdue
Frederick Davidson
Concerns: Inadequate note-keeping, communication breakdown, inappropriate nasogastric tube use, and delayed recognition/treatment of pneumothorax highlight systemic failures in patient care.
Overdue
Dominic Philip
Concerns: The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Responded