A joint National Patient Safety Alert has been issued by NHS England’s National Patient Safety team with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners about reports that patients’ penicillin allergies have been incorrectly recorded as penicillamine allergies in electronic prescribing and medicines administration (EPMA) systems. This error risks a patient with a known penicillin allergy being given a penicillin antibiotic and having a potentially fatal anaphylactic reaction.
Penicillin refers to a group of broad‑spectrum antibiotics. Penicillamine is a different medicine used to treat Wilson’s disease and severe active rheumatoid arthritis.
Required actions for primary and secondary care organisations include: forming working groups to identify affected patients; clinically reviewing and correcting allergy records; implementing additional safeguards through training and processes; and working with digital system suppliers to develop technical mitigations. All actions must be completed within 12 months.
Patients do not need to take immediate action. Healthcare staff should continue to check allergy status before prescribing or administering medicines as part of routine safety procedures. Affected patients may be contacted directly by a healthcare professional.
This alert is issued as a National Patient Safety Alert. NHS England’s National Patient Safety team was the first national body accredited to issue such alerts by the National Patient Safety Alerting Committee (NaPSAC), whose responsibilities now sit with the National Patient Safety Committee. Alerts are required to meet NaPSAC’s thresholds and standards, including working with patients, frontline staff and experts to provide clear, effective actions for safety‑critical issues.
The National Patient Safety Committee requires providers to introduce systems for planning and coordinating actions required by any National Patient Safety Alert across their organisation, with executive oversight. Failure to take required actions may lead to regulatory action by the Care Quality Commission. National Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).
