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

Summary

This national patient safety alert has been issued by the NHS England National Patient Safety team. This alert is for action by acute, community and mental health providers, health and justice services, primary care including nursing and care homes, general practice and community pharmacy.

All actions should be completed as soon as possible but no later than 20 November 2026.

Content

This alert has been issued in response to concerns of patients with penicillin allergies being incorrectly recorded as a penicillamine allergies in electronic prescribing systems. This creates a risk of a patient with a known penicillin allergy being administered a penicillin-based antibiotic and having a potentially fatal anaphylactic reaction. The risk of this error is not specific to any one electronic prescribing system.

Actions required

At health system level

Primary and secondary care organisations should form a working group across an appropriate geographical area, chaired by an appropriate chief clinical information officer, to co-ordinate implementation of the following actions:

• Identify patients recorded as having a penicillamine allergy by running a report in relevant digital systems in primary and secondary care.
• Clinically 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.

To prevent reoccurrence:

Secondary care organisations should ensure allergy guidance and training cover safe recording of allergy status in electronic prescribing systems and related digital healthcare systems, including the need to check and correct allergy status on admission and discharge.

Primary care should implement additional checks when staff (especially non-clinical staff) input allergy status into GP systems, for example, consider the need for a clinical review if penicillamine is the stated allergen.

All organisations should work with digital system suppliers and user groups to develop and deploy additional built-in mitigations to reduce the likelihood of inadvertent recording of the wrong allergy, such as adding alerts and modifying search terms. Organisations should prioritise the safe deployment of upgrades to their digital systems where suppliers have developed effective mitigations and safety features.

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