National Patient Safety Alert: 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.

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.

Actions for primary care clinicians:

• Identify patients recorded as having a penicillamine allergy
• Review the accuracy of the allergy status and amend accordingly
• Ensure allergy records in electronic prescribing and related digital systems that record allergy status are updated
• Practices should implement additional checks when staff (especially non-clinical staff) input allergy status into GP systems

Further information can be found here