Patient safety alert issued after penicillin allergies incorrectly recorded

NHS England has requested action from community pharmacy, following reports of healthcare staff recording penicillin allergies as penicillamine allergies in electronic prescribing systems.

A patient safety alert, issued on 20 November 2025, warns that “this look-alike sound-alike error” has the potential to cause patients with a known penicillin allergy to have a potentially fatal anaphylactic reaction.

Penicillamine is a drug used in the treatment of Wilson’s disease — which is an inherited condition where copper builds up in the body’s tissues — and severe active rheumatoid arthritis. It is also not an antibiotic, unlike drugs in the penicillin drug group.

The alert says that the issue was identified after a three-year review of national incident data, which identified the death of a patient, owing to 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,” it adds.

“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.”

It also explains that the error is not specific to a prescribing system and can occur in different ways, including an allergy page displaying drugs by drug name instead of group, which means that penicillamine will be the only option that comes up when typing ‘penicill’.

The safety alert says that another cause of the error could be that penicillamine appears above penicillin in an alphabetical drop-down list.

“Through record sharing, an incorrect allergy status assigned in one care setting will potentially be spread across the health system,” it adds.

It also requests action from acute, community and mental health providers, health and justice services, primary care, general practice and community pharmacy.

“This is a safety critical and complex national patient safety alert. Implementation should be co-ordinated by an executive lead (or equivalent role in organisations without executive boards) and supported by clinical leaders in clinical informatics, immunology, pharmacy, medicine and nursing,” the alert adds.

It asks that primary and secondary care organisations form a working group across a geographical area to run a report to identify patients recorded as having penicillamine allergy; clinically review the accuracy of the allergy status and amend accordingly; and ensure allergy records in electronic prescribing and other digital systems are updated.

Primary care should implement additional checks when staff, particularly non-clinical staff, input allergy status into GP systems, while secondary care should ensure there is allergy guidance and training on recording of allergy status in digital systems, it says.

In addition, the safety alert asks all organisations to work with digital suppliers to develop and deploy built-in mitigations to reduce the likelihood of recording an incorrect allergy, such as adding alerts and modifying search terms.

“The working group should strongly consider producing regular reports on allergy status until assurance has been gained that the issue is resolved,” it added.

Wing Tang, head of professional standards at the Royal Pharmaceutical Society, commented: “Accurate allergy records are vital for patient safety, and we urge healthcare teams to act quickly to review and correct any errors.

“Misrecording a penicillin allergy as penicillamine can expose patients to medicines with severe or potentially life‑threatening risks.”

“We worked with the National Patient Safety Advisory Response Advisory Panel to develop the national alert and have cascaded this with our members. We strongly encourage pharmacists and wider-healthcare teams to update records and strengthen local processes to prevent this error from occurring,” he added.

Alison Hill, principal pharmacist in medication safety and procurement at the Royal Cornwall Hospitals NHS Trust, said: “The Royal Cornwall Hospitals NHS Trust has been aware of the issue of penicillin allergies being recorded as penicillamine allergies, detailed in the recent CAS [Central Alerting System] alert, since 2019. We see an average of 17 incidents of penicillamine allergies being recorded each month, some of these are recognised immediately by the user and corrected. In order to manage this risk, we use clinical surveillance reports produced from our Careflow Medicines Management Electronic Prescribing and Medicines Administration (EPMA) system.  

“These reports are reviewed daily by our EPMA team to identify patients with a penicillamine allergy recorded, these allergies will be clinically reviewed and the allergy record amended as appropriate.  We also have an active programme for penicillin allergy de-labelling, with review of penicillin allergy labels as a standard part of our medicines reconciliation process when patients are admitted to hospital. In the past two years, with these mitigations in place, we have had one clinical incident reported due to a penicillamine allergy being recorded erroneously that resulted in no patient harm.”