National patient safety alert – harm from incorrect recording of penicillin allergy as penicillamine allergy

A joint National Patient Safety Alert has been issued by the NHS England National Patient Safety team, in collaboration with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners, about the risk of harm from inadvertently recording patients’ penicillin allergies as penicillamine allergies in electronic prescribing and medicines administration (EPMA) systems.

About this alert

There are reports of healthcare staff incorrectly recording a patient’s penicillin allergy as a penicillamine allergy in electronic prescribing systems. This 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.

The alert requires primary and secondary care organisations to form working groups to identify affected patients, clinically review and correct allergy records, implement additional safeguards in training and processes, and work with digital system suppliers to develop technical mitigations.

All actions must be completed within 12 months.

Patients do not need to take any immediate action. Healthcare staff should always check a patient’s allergy status before prescribing or administering medication as part of routine safety procedures. Affected patients may be contacted directly by a healthcare professional.

About national patient safety alerts

This alert has been issued as a National Patient Safety Alert.

The NHS England National Patient Safety team was the first national body to be accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC), whose responsibilities now come under the National Patient Safety Committee. All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards. These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues.

The National Patient Safety Committee requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight.

Failure to take the actions required under any National Patient Safety Alert may lead to the Care Quality Commission taking regulatory action. National Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).