Pharmacist missed drug contraindications
107 items
2 sources
Community pharmacists failing to identify critical drug contraindications due to confusion over clinical check duties.
Cross-Source Insight
Pharmacist missed drug contraindications has been flagged across 2 independent accountability sources:
1 inquiry rec
106 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (106) — showing 100 most recent
Alan Crabtree
Concerns: Outdated methotrexate guidelines recommend a sub-therapeutic dose and create ambiguity in responsibilities between healthcare providers, risking fatal delays in toxicity management.
Pending
Oliver Robinson
Concerns: A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Response: Curaleaf Clinic has implemented several changes following an internal investigation, including requiring specialist consultants prescribing cannabis-based medicinal products to provide evidence of competencies across all clinical practice areas. They also …
Responded
Lyn Maher
Concerns: Community pharmacists in Wales faced confusion regarding clinical checks and patient confidentiality, and had limited access to crucial drug history via the Welsh Clinical Portal, hindering safe prescribing.
Pending
Avery Hall
Concerns: A GP failed to provide specific advice on Candesartan risks during pregnancy, and the medication remained on repeat prescription, approved without review or system alerts, risking foetal harm.
Response: Riverview Surgery has implemented a new Standard Operating Protocol for prescribing medication to women of child-bearing age, which includes counselling patients and stopping contraindicated medications if pregnancy is a concern. …
Pending
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
Patrick Viles
Concerns: A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Responded
Edward Wilson
Concerns: Paramedics failed to consider the patient's significant heart failure history when administering salbutamol nebulisers, which directly impacted the outcome by lowering blood pressure.
Responded
Margaret Reeves
Concerns: Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
Responded
Abu Rahman
Concerns: Hospital staff experienced frequent Naloxone shortages leading to delayed administration and demonstrated limited awareness of opioid toxicity risks in patients with kidney impairment.
Responded
Chloe Burgess
Concerns: The severe interaction between amitriptyline, paroxetine, and ivabradine is poorly understood, not flagged by prescribing software, and prescribers lack full awareness, posing a significant toxicity risk.
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
Oliver Billings
Concerns: A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.
Responded
Margaret Feeney
Concerns: Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Overdue
Kumaran Chetty
Concerns: The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.
Responded
Imogen Heap
Concerns: There is a persistent under-appreciation of the severe risks posed by elevated Propranolol levels, a drug widely prescribed for anxiety, particularly in young people.
Responded
Margaret Daly
Concerns: A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of prescribing without adequate patient context.
Responded
Paul Clark
Concerns: Opioid painkillers were prescribed to a patient with a well-documented history of opioid addiction, without sufficient consideration or monitoring of the significant relapse risks.
Responded
John Parry
Concerns: The practice of doctors prescribing warfarin based solely on nurse-provided information, without consulting full patient records, creates a risk of incomplete data and unsafe dosing.
Responded
Raymond Watkins
Concerns: District nurses lack clear guidance and proper authorisations for administering time-critical medicines in community settings, risking delayed or incorrect treatment.
Responded
Gillian Peacock
Concerns: Critical drug interaction information recorded in patient notes was not seen or actioned by clinicians due to poor accessibility within the medical records system, impacting patient safety.
Responded
Tracy McCarthy
Concerns: Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.
Responded
Jonathan Szczepanski
Concerns: Inadequate local guidance, software warnings, and discharge documentation regarding NSAID prescribing risks, including PPI use, failed to alert prescribers to critical considerations.
Responded
Gary Ash
Concerns: Significant gaps in general medical knowledge exist regarding neuroleptic malignant syndrome management, Dantrolene's adverse effects (pulmonary oedema, drug interactions), and the diagnosis of serotonin syndrome.
Responded
Derek Hand
Concerns: Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.
Responded
Joshua Delaney
Concerns: GPs are widely unaware of Propranolol's significant fatal overdose risk, leading to potentially dangerous prescribing practices for at-risk patients and increasing the chance of future deaths.
Responded
Zulfiqar Hussain
Concerns: Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Responded
Katie Williams
Concerns: The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.
Responded
Susan Gladstone
Concerns: A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously high INR levels.
Overdue
Frederick Le Grice
Concerns: Patients and clinicians lack awareness regarding the serious lung damage risk from Nitrofurantoin. Current guidance is insufficient to ensure vigilance for symptoms and regular respiratory monitoring.
Responded
Melvyn Blount
Concerns: A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.
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
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
Michael Rolfe
Concerns: A patient with liver and renal impairment was inappropriately prescribed Rivaroxaban, a contraindicated anticoagulant, significantly increasing bleeding risk and contributing to rectal bleeding and cerebral haemorrhage.
Responded
Mathew Moore
Concerns: An unsafe amount of benzodiazepine was remotely prescribed to a patient consuming excess alcohol, without a clear policy for such circumstances or documented communication of concerns. There was also a lack of follow-up for this remote prescribing.
Responded
Natalie Mortimer
Concerns: A patient's prior overdose attempt was not updated in their GP record, leading to a GP prescribing a large, potentially unsafe quantity of medication without awareness of the patient's history.
Responded
Seema Haribhai
Concerns: Unregulated Ayurvedic practice resulted in a practitioner failing to recognize severe drug-induced liver injury and advise immediate remedy cessation. The GP also failed to adequately investigate or act on concerning symptoms.
Overdue
Marjorie Walker
Concerns: A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.
Responded
Nora Foulkes
Concerns: Advance Nurse Practitioners failed to routinely review elderly care home patients' medication regimes during multiple visits, missing critical errors due to time constraints, posing a significant risk to patient safety.
Responded
Faizan Nazar
Concerns: The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.
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
Jane Allison
Concerns: The BNF content for Nitrofurantoin was deficient in advising on monitoring for sudden pulmonary deterioration in elderly, active patients, even for short treatment courses.
Responded
Sharon Robinson
Concerns: There is a concern that patient sensitivities to antibiotics are ignored, leading to medication being administered despite potential risks.
Responded
Elaine Inns
Concerns: Powerful painkillers, including liquid morphine, were continued despite known significant alcohol use and the patient's non-adherence to dosage instructions, posing a significant risk.
Responded
Samantha Singh
Concerns: A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.
Overdue
Fiona Humberstone
Concerns: A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.
Overdue
Bruce Houghton
Concerns: The deceased missed an annual medication review, and such reviews fail to inquire about patients' over-the-counter medication use, risking adverse drug interactions.
Responded
Andrew Biddlecombe
Concerns: The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.
Responded
Katie Corrigan
Concerns: There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Responded
Natalie Edgington
Concerns: Prescribers issued methadone without sufficient information on the patient's liver disease, relying on self-reporting and failing to consider a lower starting dose.
Responded
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
Ann Schuetz
Concerns: Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.
Overdue
Claire Richards
Concerns: There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the leakage of medication from lawful dispensing into criminal hands.
Overdue
Eileen Brindley
Concerns: An antibiotic was prescribed despite a recorded allergy, with no evidence the clinician noted it or consulted the patient, highlighting insufficient visibility of adverse reaction entries in medical records.
Responded
Viktor Scott-Brown
Concerns: A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.
Responded
Mary Nelson
Concerns: Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
Overdue
Shanté Turay-Thomas
Concerns: GPs failed to ensure specialist allergy care, provided inadequate advice on carrying two adrenaline pens, and did not offer training for new auto-injector devices, compounded by deficient CCG guidance on dosage.
Responded
Katherine Stamp
Concerns: The serious side effects of clozapine, particularly regarding smoking and pneumonia, are under-appreciated by prescribers and not sufficiently detailed in national guidance.
Overdue
Liane Davenport
Concerns: 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.
Responded
Abdeslam Benelghazi
Concerns: Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.
Responded
Graham Earl
Concerns: GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Overdue
Graham Saffery
Concerns: The BNF, a key GP resource, lacks warnings for co-prescribing amitriptyline and oxycodone, despite other guidance recommending caution and monitoring for this interaction.
Responded
Christopher Summerhayes
Concerns: 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.
Responded
Deborah Chapman
Concerns: Medical records failed to show adequate inquiry into illicit drug misuse, preventing informed risk assessments for prescribing medications with known respiratory side effects, and lacked a system for recording such information.
Responded
Mohammed Ahmed
Concerns: Combined use of Olanzapine and Spice caused a fatal allergic reaction, yet Olanzapine continued to be prescribed. Clinicians may lack national awareness of serious drug interactions and side effects with Olanzapine.
Overdue
Chand Ali
Concerns: 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.
Responded
Theresa Feehan
Concerns: The practice's medication review system was inadequate, with outdated patient records and poor correlation between problem lists and prescribed drugs. This led to dangerous medications being continued and a lack of proper rationale for prescribing.
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
Jennifer Lacey
Concerns: Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.
Overdue
Paul Ryley
Concerns: Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
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
Pauline Pryor
Concerns: Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.
Responded
Stuart Walls
Concerns: The patient died from a synergistic toxic effect of multiple prescribed drugs, each within therapeutic range, affecting the central nervous system and respiration. Prescribing practices need to account for cumulative drug interactions.
Overdue
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
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
Theresa Thompson
Concerns: A post-splenectomy patient died from Streptococcus pneumonia due to lack of lifelong antibiotic prophylaxis and vaccination. Mixed messages about antibiotic use may deter patients from accepting crucial preventative treatments.
Overdue
Charles Rendell
Concerns: There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Responded
Richard Breatnach
Concerns: Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.
Overdue
Edward Mallen
Concerns: A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
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
Kinga Cieciorska
Concerns: Missed opportunities to investigate abnormal ECG and tachycardia led to delayed diagnosis. Systemic failures in information recording and transmission, coupled with unconsidered medication contraindications, contributed to inadequate care.
Overdue
Patricia Thomas
Concerns: A significant lack of awareness among health professionals regarding the dangerous interaction between Miconazole Gel and Warfarin, combined with unclear information resources, risks uncontrolled bleeding.
Overdue
Irene Pearson
Concerns: Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate prescribing and unclear, scanty GP electronic notes contributed to unsafe care.
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
Wayne O’Neill
Concerns: 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.
Responded
Dorothy Delaney
Concerns: 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.
Overdue
Lynn Poyser
Concerns: Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.
Overdue
Andre Mickley
Concerns: Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.
Overdue
Isaac Bahar
Concerns: A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
Responded
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
Beryl Walters
Concerns: Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
Overdue
Christopher Davies
Concerns: Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
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
John Day
Concerns: Out-of-hours doctors lack crucial access to patient medical records, particularly allergy information, increasing the risk of incorrect medication prescriptions when patients provide inaccurate details or lack capacity.
Responded
Lisa Webb
Concerns: Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
Overdue
Akua Anokye-Boateng
Concerns: There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell disease, particularly concerning routine GI protection.
Responded
Dafydd Watts
Concerns: Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
Overdue
Nicos Michael
Concerns: Critical patient allergy information was fragmented across multiple hospital records, inconsistently recorded, and not readily available, indicating systemic failures in allergy documentation and communication.
Responded
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
Joseph Godfrey
Concerns: Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed to follow observation protocols, document checks, or access medical history, and BUPA's investigation was insufficient.
Overdue
Kerry Jacobs
Concerns: 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.
Responded