Poor medicines audit response
55 items
1 source
Failure to promptly respond to findings from medicines audits and seek current guidance on medication management.
Cross-Source Insight
Poor medicines audit response has been flagged across 1 independent accountability source:
55 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (55)
Anthony Lodge
Concerns: Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Response: International Scientific Supplies Ltd disputes the concern, stating their urine specimen containers are manufactured and labelled according to regulations, with expiry dates and batch numbers on outer packaging. They assert …
Responded
Ashana Charles
Concerns: Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers and health providers.
Response: NHS England notes the British Pharmaceutical Nutrition Group (BPNG) has issued a position statement recommending 1.2 μm filters for all parenteral nutrition admixtures and has written to BAPEN and RCN …
Overdue
Nicola Mulliss
Concerns: A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Responded
Venetia Pierce
Concerns: An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's pulmonary risks in the elderly.
Overdue
Robert Simpson
Concerns: A patient was discharged with incorrect medication and missed critical antibiotic doses due to stock issues and poor communication, highlighting systemic failures in medication management and escalation.
Responded
Christopher Bradbury
Concerns: A national lack of knowledge and guidelines for Severe Invasive Soft Tissue Infections, combined with ineffective training and an absence of an audit trail for omitted medication doses, creates significant patient safety risks.
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
Teresa Auriemma
Concerns: Doctors repeatedly failed to follow policy for hypokalaemia, resulting in inadequate daily monitoring of potassium levels and inappropriate administration of intravenous potassium, despite prior inquests highlighting similar electrolyte monitoring failures.
Responded
Gemma Ralph
Concerns: Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.
Responded
Shahida Khan
Concerns: A patient received toxic and fatal quantities of medication from care home staff through an unknown mechanism, highlighting an unexplained risk of recurring, lethal medication errors.
Responded
David Morris
Concerns: Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.
Responded
Debra Bates
Concerns: A recommendation for restricted medication dispensing to manage chaotic pill use was rejected due to perceived logistical issues, without adequately exploring implementation strategies or system safeguards.
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
Teresa Bennett
Concerns: Widespread non-compliance with medication review targets and a lack of standardised review practices led to insufficient patient advice, increasing the risk of inadvertent overdose from combined medications.
Responded
Hazel Pearson
Concerns: Inadequate management of food intolerances and allergies, including slow implementation of safety measures and a lack of proper incident investigation and Datix reporting, poses a serious risk.
Responded
Glenn Lockwood
Concerns: Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Responded
Mohammed Hussain
Concerns: Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn and improve patient safety.
Responded
John Abrahams
Concerns: Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.
Responded
Beryl Ellison
Concerns: Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Overdue
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
Trevor Reynolds
Concerns: The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.
Responded
Alan Hodgson
Concerns: Failures in opiate administration, senior doctor review, adherence to established pathways, inter-departmental communication, and continuity of care were compounded by an insufficient internal review process.
Overdue
Margaret Toye
Concerns: Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.
Overdue
Karen Redding
Concerns: Care staff failed to check medication contents upon request and did not ensure a doctor's review after the resident disclosed an overdose, despite her declining help.
Responded
Mohammed Salam
Concerns: The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.
Responded
Kumbulani Mtombeni
Concerns: Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.
Responded
Rhian Roberts
Concerns: Concerns include uncertainty over toxicology screening, delays in updating critical blood result communication protocols, and systemic failures in investigating and learning from adverse incidents.
Overdue
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
Ian Allen
Concerns: The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.
Responded
Theresa Robertson
Concerns: The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Overdue
Mildred Horrex
Concerns: Poor record-keeping, including insufficient and inaccurate admission information, led to an inadequate fall risk assessment. Additionally, monthly drug audits failed to identify critical discrepancies between medication charts and actual stock.
Overdue
Peter Cole
Concerns: Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Responded
Elaine Renshaw
Concerns: Inadequate controlled drug check processes in care homes resulted in unaccounted drugs and inaccurate stock sheets, highlighting a national lack of clear guidelines for controlled drug handling and recording.
Overdue
Sandra Scott
Concerns: A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.
Overdue
Michael Lobban
Concerns: Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions for such discrepancies.
Overdue
Feni Lee
Concerns: An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.
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
Joan Wright
Concerns: Issues included inconsistent opioid handling, unaddressed statutory oversight for drug responsibilities, police failure to recognise safeguarding risks in medication errors, and a lack of statutory definition for "regular" medication checks in care homes.
Responded
Thomas Jackson
Concerns: Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.
Overdue
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
Kathleen Bamforth
Concerns: Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Responded
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
Kay Morrison
Concerns: There is an insufficient system for collating appropriate antibiotic history, potentially across many hospitals, and a lack of clear requirements for Trusts to adhere to national guidelines on this crucial patient information.
Overdue
Michael Mahon
Concerns: The crucial annual clozapine test was missed, and there was no system in place to identify this omission, allowing symptoms undetectable by monthly checks to go unnoticed.
Overdue
Benjamin Brown
Concerns: Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
Overdue
Margaret Hions
Concerns: Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Responded
Maureen Chatterley
Concerns: Lack of investigation into alleged medication overdose and inadequate stock control for non-controlled drugs on wards, preventing verification of medication quantities and increasing risk of misuse or error.
Responded
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
William Bows
Concerns: There was a lack of protocols and guidance for primary and secondary care providers on monitoring patients prescribed Amiodarone, particularly concerning liver, thyroid, and respiratory function during the initial treatment period.
Responded
Paul Hardy
Concerns: Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Overdue
Judith Saville
Concerns: Over-prescription of medication to a patient with a history of overdoses was identified. There was a lack of a robust computer system to warn practitioners about overdose history, and an action plan's implementation needed auditing.
Responded
Mr Pether
Concerns: Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Overdue
Peter Brookes
Concerns: Concerns include hospital administration of Parkinson's medication not following patient regimens, unavailability of doctors for weekend reviews, and an unresolved dispensing error causing wrong medication.
Responded
Lee Curran
Concerns: PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Overdue
Judith Marshall
Concerns: 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.
Response: The General Pharmaceutical Council outlines its regulatory standards and inspection processes, stating it will continue to monitor pharmacies and take action where standards are not met. They are considering publishing …
Response: NHS England published a Patient Safety Alert in March 2014 to improve medication error reporting, including establishing a National Medication Safety Network and identifying medication safety officers. They also plan …
Response: The Royal Pharmaceutical Society plans to raise awareness and encourage the use of 'read-back' and additional checks in future guidance to reduce dispensing errors. They noted that software for error …
Response: The Department of Health highlights new EU pharmacovigilance legislation that expanded reporting to include medication errors. The MHRA has introduced an integrated reporting route with NHS England and is establishing …
Responded