Unsafe medication management
Failures in the safe management of medicines, including storage, administration, record-keeping, prescribing, and disposal.
454 items
11 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
83match
We Can Recover CIC
Training records provided recorded only two of the four registered nurses had completed medicine administration training. The process around clinical oversight and supervision of registered nurses in medicine management remained unclear. The service had not implemented a safe system and process to safely prescribe and store medicines. The registered manager could not provide additional clarity on the prescribing...
Matched on
terms: management, medication
Committee recommendation
78match
#24 - Commission independent review into hospital medicines management, focusing on automation and digital systems.
We recommend that an independent review is commissioned to explore hospital medicines management, to report within one year. The review should make recommendations, particularly around how the potential of automation and technological systems like connected medication management could be realised and how learning from Global Digital Exemplars can be built upon in Trusts across England. (Paragraph 131) Pharmacy...
Matched on
terms: management, medication
PFD report
77match
Kymberley Holden
Persistent unsafe prescribing of controlled drugs and inadequate understanding of reporting serious incidents, compounded by poorly coordinated management for neurological patients, pose ongoing risks.
Matched on
terms: management, unsafe
CQC action
77match
Unit 4 Cornishway Industrial Estate
Provide care and treatment in a safe way for service users by ensuring the proper and safe management of medicines. Staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept under review. Staff must follow policies and procedures about managing medicines.
Matched on
terms: management, medication
PFD report
73match
Andrew Aitken
Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Matched on
terms: management, medication
PFD report
73match
Percy Jacks
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Matched on
terms: management, medication
PFD report
73match
Sandra Miller
Urgent action is required to stop unsafe practices with open-ended urinary catheters, establish proper management procedures, and ensure all staff are adequately trained in catheter care.
Matched on
terms: management, unsafe
CQC action
73match
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with unsafe management of medicines and insufficient medicines stocks.
Matched on
terms: management, unsafe
CQC action
73match
Valewood House Nursing Home
People were not protected against the risks associated with the unsafe use and management of medicines.
Matched on
terms: management, unsafe
CQC action
73match
Reside at Southwood
The provider must ensure that people are protected against the risks associated with the unsafe management and use of medicines.
Matched on
terms: management, unsafe
CQC action
73match
Haisthorpe House
The provider must ensure people who used services are protected against the risks associated with unsafe use and management of medicines.
Matched on
terms: management, unsafe
CQC action
73match
Benthorn Lodge
The registered person had not protected people against the risk of unsafe management of medicines. The systems in place to ensure medicines were administered safely were not consistently followed.
Matched on
terms: management, unsafe
CQC action
73match
Slate House Residential Home
The provider must ensure appropriate arrangements are in place for administering medicines to protect people against the risks associated with unsafe use and management of medicines.
Matched on
terms: management, unsafe
CQC action
71match
Epilium & Skin
The service must implement and maintain consistent, safe medicines management. This must include safe procedures in line with national requirements that include storage, stock management, prescribing, administration, and destruction.
Matched on
terms: management
PFD report
69match
Beatrice Gatt
A critical antipsychotic medication was not administered due to a transfer error between medication sheets, highlighting a lack of formal training for nursing staff on medication management.
Matched on
terms: management, medication
PFD report
69match
Jonathan Earp
Inadequate management of prescribed Fentanyl patches meant 'unspent' medication was not accounted for, and staff failed to consider the cumulative effect of Fentanyl and suspected illicit drug use.
Matched on
terms: management, medication
PFD report
65match
Harold Elvidge
A risk of fluid mix-ups exists due to inconsistent safety standards and storage policies across the trust, particularly in non-critical care settings, necessitating a trust-wide review of fluid management.
Matched on
terms: management
PFD report
65match
Edward Devlin
Nurses reportedly slid medication, including dangerous drugs, under locked cell doors, leading to uncertainty about patient consumption, compromised dispensing records, and risks of drug trading or stockpiling for overdose.
Matched on
terms: medication
PFD report
65match
Songul Bozdag
The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Matched on
terms: medication
PFD report
65match
Hayley Sheehan
The repeat prescription procedure is unsafe as it relies on manual flagging of early requests, with software unable to automatically identify them. More safeguards are needed, including software adaptation.
Matched on
terms: unsafe
CQC action
65match
Verve Health
The service must ensure they use systems and processes to safely prescribe, administer and record medicines and that the clinic room and medication is secure.
Matched on
terms: medication
CQC action
65match
Trent Lodge Residential Care Home
The provider must ensure service users and others are protected against the risks associated with the unsafe storage of medicines.
Matched on
terms: unsafe
CQC action
65match
Russell Churcher Court
The provider must ensure that care and treatment is provided in a safe way for service users, specifically regarding the safe management and administration of medicines.
Matched on
terms: management
CQC action
65match
Laburnum Court Care Centre
The provider must ensure that systems, processes and record keeping relating to the management of medicines are robust.
Matched on
terms: management
PPO recommendation
64match
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession medication that has not been collected.
Matched on
terms: management, medication
IMB annual report
64match
North East Midlands, Yorkshire & Humber STHF (2023)
This is the first annual report for the North East Midlands, Yorkshire & Humberside IMB, covering Short-Term Holding Facilities (STHFs) from February 2022 to January 2023. While staff conduct and detainee treatment generally received positive feedback, significant concerns arose regarding the unsafe opening and managing large intakes at Swinderby Residential STHF. The Board also highlighted the critical and...
Matched on
terms: medication, unsafe
IMB annual report
64match
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Scotland and Northern Ireland STHF IMB report highlights generally humane treatment by staff but identifies significant concerns across multiple facilities for the period February 2022 to January 2023. Key issues include the unsafe removal of prescription medication, inadequate disability provisions, and the unsuitability of airport holding rooms for increasingly prolonged detentions. The Board also notes long-overdue building...
Matched on
terms: medication, unsafe
IMB recommendation
64match
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
Matched on
terms: medication
IMB recommendation
64match
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective...
Matched on
terms: management, medication
PHSO casework decision
64match
P-003729 - Portsmouth Hospitals University NHS Trust
Mr O complains about the inpatient care his wife received from the Trust from May to July 2021. This included premature discharge, inappropriate medication management and poor record keeping.
Matched on
terms: management, medication
Committee recommendation
62match
#168 - Implement new secure systems for distributing and administering prison medication to prevent diversion.
HMPPS should conduct an urgent review of all prescription medication dispensing procedures within prisons to identify and close loopholes exploited for diversion and introduce enhanced supervision of medication queries. New secure systems for distributing and administering medication must be implemented immediately to prevent diversion and protect vulnerable prisoners. (Recommendation, Paragraph 39) Drivers of the demand and impact of...
Matched on
terms: medication
PFD report
61match
Richard White
Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Matched on
terms: medication
PFD report
61match
Derrick Rivers
The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Matched on
terms: management
PFD report
61match
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
terms: medication
PFD report
61match
Iris Grimwood
Inadequate nursing staff levels, compounded by recruitment and training difficulties, led to significant mistakes in patient care, including incorrect medication application and improper use of medical equipment.
Matched on
terms: medication
PFD report
61match
Alan Peck
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.
Matched on
terms: medication
PFD report
61match
Philip Allen
The GP surgery's repeat prescription system failed to prevent the continued prescribing of a medication after a specialist advised stopping it, indicating a risk of medication errors.
Matched on
terms: medication
PFD report
61match
Moses McDonald
The Clozapine clinic failed to conduct mandatory and regular glucose testing for patients receiving antipsychotic medication, posing a significant safety concern.
Matched on
terms: medication
PFD report
61match
Lottie Reid
There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.
Matched on
terms: medication
PFD report
61match
Geoffrey Parry
Critical ECG test results were unavailable pre-surgery due to systemic record management issues. An unlabelled intravenous line was accidentally disconnected, highlighting a lack of clear labelling protocols.
Matched on
terms: management
PFD report
61match
Lyndsey Holt
Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Matched on
terms: unsafe
PFD report
61match
Ronald Brewer
Inadequate administration, documentation, and dispensation processes for medications, especially palliative ones, posed risks in the care home.
Matched on
terms: medication
PFD report
61match
Russell Robb
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Matched on
terms: medication
CQC action
61match
Aaron Abbey Care Services Limited
The registered person must ensure that care and treatment is provided in a safe way for service users, and ensure the proper and safe management of medicines.
Matched on
terms: management
CQC action
61match
Redcot Lodge Residential Care Home
The provider must do all that is reasonably practicable to mitigate risk and ensure the proper and safe management of medicines.
Matched on
terms: management
CQC action
61match
Bindon Residential Home
The provider must ensure the safe management of medicines.
Matched on
terms: management
CQC action
61match
Westwood Care Home
The provider failed to ensure proper and safe management of medicines. This is a continued breach of regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 12(2)(g)
Matched on
terms: management
CQC action
61match
The Goddards
The provider must ensure staff follow relevant guidance to ensure proper and safe management of medicines.
Matched on
terms: management
CQC action
61match
The Beacon
The provider had failed to ensure the proper and safe management of medicines.
Matched on
terms: management
CQC action
61match
Suite 4, Jason House
The provider must ensure proper and safe management of medicines.
Matched on
terms: management