National Patient Safety Alert: Harm from incorrect recording of a penicillin allergy as a penicillamine allergy

National Patient Safety Alert Reference Number: NatPSA/2025/006/NHSPS

Date issued: 20 November 2025

Explanation of identified safety issue

There are reports of healthcare staff recording a patient’s penicillin allergy as a penicillamine allergy in electronic prescribing systems. This look-alike sound-alike error risks a patient with a known penicillin allergy being administered a penicillin based antibiotic and having a potentially fatal anaphylactic reaction.

‘Penicillin’ describes a group of broad-spectrum penicillin-based antibiotics. Penicillamine is a drug used to treat Wilson’s disease and severe active rheumatoid arthritis – it is not an antibiotic.

Electronic prescribing systems assign allergy status in different ways and local configurations in trusts and other organisations may differ. The risk of this error is not specific to any one electronic prescribing system. It arises because clinicians are either presented with:

  1. an allergy page displaying drugs by drug name or group. ‘Penicillin’ is a drug group and therefore not an option in the ‘drug name’ search. Penicillamine will be the only option presented when ‘penicill’ is the search term; or
  2. an alphabetical drop-down list of both drug names and groups: penicillamine comes above penicillin. Through record sharing, an incorrect allergy status assigned in one care setting will potentially be spread across the health system.

A 3-year review of national incident data identified the death of a patient because of an anaphylactic reaction to a penicillin-based antibiotic. They were inadvertently prescribed this antibiotic because their known penicillin allergy had been recorded as penicillamine allergy on their GP record. All other relevant incidents were recorded as low or no harm due to the work of healthcare staff to identify the issue before it became clinically significant.

Actions required

Actions to be completed as soon as possible but no later than 20 November 2026

At health system level

  1. Primary and secondary care organisations should form a working group across an appropriate geographical area, chaired by an appropriate chief clinical information officer, to co-ordinate implementation of the following actions:
    1. Identify patients recorded as having a penicillamine allergy by running a report in relevant digital systems in primary and secondary care.
    2. Clinically review the accuracy of the allergy status and amend accordingly.
    3. Ensure allergy records in electronic prescribing and related digital systems that record allergy status are updated.

To prevent reoccurence:

  1. Secondary care organisations should ensure allergy guidance and training cover safe recording of allergy status in electronic prescribing systems and related digital healthcare systems, including the need to check and correct allergy status on admission and discharge.
  2. Primary care should implement additional checks when staff (especially non-clinical staff) input allergy status into GP systems, eg consider the need for a clinical review if penicillamine is the stated allergen.
  3. All organisations should work with digital system suppliers and user groups to develop and deploy additional built-in mitigations to reduce the likelihood of inadvertent recording of the wrong allergy, such as adding alerts and modifying search terms. Organisations should prioritise the safe deployment of upgrades to their digital systems where suppliers have developed effective mitigations and safety features.
  4. The working group should strongly consider producing regular reports on allergy status until assurance has been gained that the issue is resolved.

Please see the full guidance in the alert.

The post National Patient Safety Alert: Harm from incorrect recording of a penicillin allergy as a penicillamine allergy appeared first on Community Pharmacy England.