A joint National Patient Safety Alert has been issued by NHS England’s National Patient Safety team together with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners. The alert warns that some electronic prescribing and medicines administration (EPMA) systems have incorrectly recorded patients’ penicillin allergies as penicillamine allergies.
This recording error creates a serious safety risk: a person known to be allergic to penicillin could be prescribed a penicillin antibiotic and suffer a potentially fatal anaphylactic reaction. Penicillamine is an entirely different medicine, used for conditions such as Wilson’s disease and some cases of severe active rheumatoid arthritis, while penicillin describes a group of broad‑spectrum antibiotics.
Required actions for primary and secondary care organisations include: setting up multidisciplinary working groups to identify patients affected by the error; clinically reviewing and correcting allergy records; introducing additional safeguards through staff training and updated processes; and working with digital system suppliers to build technical mitigations in EPMA systems. These actions must be completed within 12 months.
Patients do not need to act immediately. Routine safety practice remains essential: healthcare professionals should always confirm allergy status before prescribing or administering medicines. Clinicians or other healthcare staff may contact patients identified as affected to review and update their records.
This notice is issued as a National Patient Safety Alert. The NHS National Patient Safety team was the first national body accredited to issue such alerts by the former National Patient Safety Alerting Committee, whose functions now sit with the National Patient Safety Committee. Alerts must meet national thresholds and standards and are developed with input from patients, frontline staff and subject experts to ensure clear, practical actions for safety‑critical issues.
The National Patient Safety Committee expects provider organisations to have systems, planning and executive oversight in place to coordinate and complete required actions. Failure to comply could result in regulatory action by the Care Quality Commission. National Patient Safety Alerts are distributed rapidly to providers through the Central Alerting System (CAS).
