Pharmacist missed drug contraindications
Community pharmacists failing to identify critical drug contraindications due to confusion over clinical check duties.
189 items
8 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
73match
Kinga Cieciorska
A missed opportunity to investigate abnormal ECG trace and tachycardia; systemic failings in recording and transmission of information, with GP medical notes not seen by the Junior Doctor; details of medication including the significance of the drug, Diclofenac, was not considered.
Matched on
terms: drug, missed
PPO recommendation
73match
The Head of Healthcare, lead GP and lead pharmacist at HMP Wandsworth
The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’.
Matched on
terms: contraindication, pharmacist
PFD report
69match
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: contraindication, drug
PFD report
69match
Sneh Chaudhry
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.
Matched on
terms: drug
Inquiry recommendation
69match
IHRD-25 - Drug Prescription Documentation
All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of correction the pharmacist should inform the prescribing clinician.
Matched on
terms: drug, pharmacist
PFD report
65match
Teresa Lonergan
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Matched on
terms: drug
PFD report
65match
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: missed
PFD report
65match
Gabriele Kreichgauer
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.
Matched on
terms: missed
Committee recommendation
62match
#26 - English pharmacists twice as likely to prescribe antibiotics for sore throats than Welsh counterparts.
Under the Pharmacy First scheme introduced in early 2024, patients can now consult pharmacists directly for several minor illnesses and conditions that previously required a GP visit and the pharmacist can prescribe medicines if necessary. NHS England commented that early evidence from Pharmacy First was that GPs were following the relevant protocols, and it had not seen any...
Matched on
terms: pharmacist
PFD report
61match
Carol Ann Gibson
A GP ignored a critical adverse drug reaction alert, exacerbated by a culture of 'alert fatigue' and dismissive attitudes towards patient safety warnings within the medical practice.
Matched on
terms: drug
PFD report
61match
Michael Anthony
The coroner noted that the deceased's Gabapentin level was five times the normal therapeutic level, the reason for which was undetermined, and that the drug is usually not prescribed in diabetics due to the risk of severe reaction.
Matched on
terms: drug
PFD report
61match
Pauline Pryor
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.
Matched on
terms: missed
PFD report
61match
Jennifer Lacey
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.
Matched on
terms: drug
PFD report
57match
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: pharmacist
PFD report
57match
Dafydd Watts
Drug literature and the British National Formulary fail to adequately inform physicians about rare but potential fatal occurrences associated with medication.
Matched on
terms: drug
PFD report
57match
Andre Mickley
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.
Matched on
terms: drug
PFD report
57match
Richard Breatnach
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.
Matched on
terms: drug
PFD report
57match
Stuart Walls
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.
Matched on
terms: drug
PFD report
57match
Theresa Feehan
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.
Matched on
terms: drug
PFD report
57match
Mohammed Ahmed
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.
Matched on
terms: drug
PFD report
57match
Deborah Chapman
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.
Matched on
terms: drug
PFD report
57match
Mary Nelson
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.
Matched on
terms: drug
PFD report
53match
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.
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classifier match
PFD report
49match
John Michael Bailey
Date of report: 09/09/2013 Ref: 2013-0198 Deceased name: John Michael Bailey Coroners name: Jullian Fox Coroners Area: South Yorkshire (West) Category: Community health care and emergency services related deaths This report is being sent to: Department of Health and Social Care
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classifier match
PFD report
49match
Joseph Godfrey
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.
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PFD report
49match
Peter Rowe
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.
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classifier match
PFD report
49match
Edward Mallen
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.
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classifier match
PFD report
49match
Theresa Thompson
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.
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PFD report
49match
Paul Ryley
Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
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PFD report
49match
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.
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PPO recommendation
48match
The Head of Healthcare, the lead GP and the senior pharmacist at HMP Wandsworth
The Head of Healthcare, the lead GP and the senior pharmacist should review the glyceryl trinitrate and aspirin PGDs to ensure that staff are able to use these emergency medications in all situations where they are indicated and ensure that the inclusion criteria takes account of the additional presentation of a cardiac event without pain in diabetic patients.
Matched on
terms: pharmacist
IMB recommendation
48match
Cardiff (2025)
How will the Health Board ensure that prescribing checks at HMP Cardiff are resolved quickly, given that the pharmacists’ job-sharing arrangement prevents in-prison checks?
Matched on
terms: pharmacist
PFD report
45match
Bertram Hamilton
The coroner was concerned that a nurse appeared not to know that insulin should not be given to a person whose blood sugars were so low.
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PFD report
45match
Nicos Michael
The coroner identified conflicting evidence regarding the deceased's recorded allergies, noting a lack of readily available and continuously updated allergy information for hospital staff, and that electronic prescribing was not compulsory.
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PFD report
45match
Akua Anokye-Boateng
The report raises concerns about the use of NSAIDs in children with sickle cell disease, specifically regarding the potential for a single dose to cause GI damage and the lack of clear guidance on gastro-intestinal protection measures.
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PFD report
45match
Lisa Webb
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.
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PFD report
45match
John Day
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.
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PFD report
45match
Jessica Bond
Propess was inappropriately administered to a patient with a prior caesarean section, despite the known risk of uterine rupture and associated complications.
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PFD report
45match
Christopher Davies
Insufficient communication to patients and staff regarding the interaction between clozapine, caffeine, and smoking, as well as warning signs of toxicity.
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PFD report
45match
Beryl Walters
Cyclizine, a medication with known cardiac risks in severe heart failure, was unnecessarily administered despite a safer alternative being available, posing avoidable patient harm.
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PFD report
45match
Marjorie Ellery
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.
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PFD report
45match
Isaac Bahar
A patient with advanced kidney disease was fatally prescribed Codeine, directly breaching hospital policy and national guidance on medication for vulnerable patients.
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PFD report
45match
Lynn Poyser
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.
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PFD report
45match
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.
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PFD report
45match
Irene Pearson
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.
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PFD report
45match
Patricia Thomas
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.
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classifier match
PFD report
45match
Charles Rendell
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.
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PFD report
45match
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.
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PFD report
45match
Paul Mullen
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.
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PFD report
45match
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.
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