Poor medicines audit response
Failure to promptly respond to findings from medicines audits and seek current guidance on medication management.
76 items
6 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
78match
Applegarth Care Home
The service to seek current guidance on how to respond promptly to findings from medicines audit.
Matched on
terms: audit, medicine
PFD report
73match
Mildred Horrex
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.
Matched on
terms: audit, poor
CQC action
69match
Colney Lodge Limited
The provider must ensure medicine audits are in place. Medicine administration records (MAR) must be completed accurately and not signed ahead of time. Risk assessments must be in place for managing refusal of medication.
Matched on
terms: audit, medicine
CQC action
68match
Sydenham House
Establish a programme of medicines auditsto ensure staff are practicing in line with current guidance.
Matched on
terms: audit, medicine
PFD report
65match
Kumbulani Mtombeni
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.
Matched on
terms: audit
PFD report
61match
Judith Saville
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.
Matched on
terms: audit
PFD report
61match
Benjamin Brown
Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
Matched on
terms: audit
PFD report
61match
Theresa Robertson
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.
Matched on
terms: audit
PFD report
61match
Ian Allen
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.
Matched on
terms: poor
PFD report
61match
Norman Leadbeater
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.
Matched on
terms: audit
PFD report
61match
David Morris
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.
Matched on
terms: poor
PFD report
61match
Christopher Bradbury
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.
Matched on
terms: audit
CQC action
60match
Head Office
We recommend that the provider reviews their medicine administration auditing processes to ensure safe administration of medicines at all times.
Matched on
terms: audit, medicine
PFD report
57match
Thomas Jackson
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.
Matched on
terms: poor
PFD report
57match
Michael Lobban
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.
Matched on
terms: audit
PFD report
57match
Trevor Reynolds
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.
Matched on
terms: audit
PFD report
57match
Seema Haribhai
The report identifies that an Ayurvedic practitioner did not recognise that the cause of a patient's yellow discolouration might be her own prescription, and GPs did not record details of patient history or advise immediate cessation of Ayurvedic medicines.
Matched on
terms: medicine
PFD report
57match
Gemma Ralph
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.
Matched on
terms: audit
PFD report
53match
Joan Wright
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.
Matched on
classifier match
PFD report
53match
Feni Lee
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.
Matched on
classifier match
PFD report
53match
Mohammed Hussain
The report identifies issues with monitoring clozapine levels, a lack of a safe system to communicate high clozapine levels or effect medication changes, and a lack of understanding of when to measure and how to respond to high clozapine levels; concerns were also raised about pharmacy resourcing and the quality of internal investigations.
Matched on
classifier match
PFD report
53match
David Crompton
The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
Matched on
classifier match
CQC action
52match
Tralee Rest Home
Medication audits had failed to identify that equipment used to check blood sugar levels was not calibrated, or that there was no stock of calibration fluid held within the service.
Matched on
terms: audit
CQC action
52match
Oak Tree Manor
There were medication audits but like the other audits they did not pick up on the areas identified at the inspection.
Matched on
terms: audit
PFD report
49match
Peter Brookes
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.
Matched on
classifier match
PFD report
49match
Kathleen Neville
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.
Matched on
classifier match
PFD report
49match
Maureen Chatterley
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.
Matched on
classifier match
PFD report
49match
Kathleen Bamforth
Concerns exist regarding current practice guidelines for clomipramine prescription, specifically the merits of routine blood screens for patients on long-term use.
Matched on
classifier match
PFD report
49match
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
classifier match
PFD report
49match
Sandra Scott
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.
Matched on
classifier match
PFD report
49match
Peter Cole
Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Matched on
classifier match
PFD report
49match
Katie Corrigan
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.
Matched on
classifier match
PFD report
49match
Mohammed Salam
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.
Matched on
classifier match
PFD report
49match
Margaret Toye
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.
Matched on
classifier match
PFD report
49match
Alan Hodgson
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.
Matched on
classifier match
PFD report
49match
Karen Redding
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.
Matched on
classifier match
PFD report
49match
Beryl Ellison
Inadequate supervision of syringe medication and unchanged care home systems, despite prior family concerns, contributed to a resident's fatal overdose of oxycodone.
Matched on
classifier match
PFD report
49match
Hazel Pearson
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.
Matched on
classifier match
PFD report
49match
Teresa Bennett
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.
Matched on
classifier match
PFD report
49match
Debra Bates
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.
Matched on
classifier match
PFD report
49match
Shahida Khan
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.
Matched on
classifier match
PFD report
49match
Teresa Auriemma
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.
Matched on
classifier match
PPO recommendation
48match
The Head of Healthcare
The Head of Healthcare should ensure that the new measures in place are audited at frequent intervals to ensure that pain relief and end of life medications are sourced and dispensed in a timely manner.
Matched on
terms: audit
PPO recommendation
48match
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should investigate whether Parc followed the PGD regulations and whether the use of verbal instructions by GPs for nurses to dispense prescription-only medicines from the out-of-hours medication cupboard complies with regulations.
Matched on
terms: medicine
PFD report
45match
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
classifier match
PFD report
45match
Lee Curran
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.
Matched on
classifier match
PFD report
45match
Mr Pether
Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Matched on
classifier match
PFD report
45match
Paul Hardy
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.
Matched on
classifier match
PFD report
45match
William Bows
The report identifies a lack of protocols for advising primary care providers on monitoring patients prescribed Amiodarone, specifically concerning liver function, thyroid tests, and respiratory difficulties.
Matched on
classifier match
PFD report
45match
Margaret Hions
Inadequate adherence to clinical pharmacy policy regarding tinzaparin prescribing, blood level monitoring, and creatinine clearance monitoring posed risks to patient safety.
Matched on
classifier match