Harm from incorrect recording of a penicillin allergy as a penicillamine allergy

NHS England has published a National Patient Safety Alert, in collaboration with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners on the risk of harm from healthcare staff incorrectly recording patients’ penicillin allergies as penicillamine allergies in electronic prescribing systems. 

This error can result in patients with known penicillin allergies being prescribed penicillin-based antibiotics, increasing the risk of a potentially fatal anaphylactic reaction.

Primary and secondary care organisations must form working groups to identify and review affected patients’ records and act appropriately to correct any inaccuracies, implement additional safeguards in training and processes, and work with digital system suppliers to develop technical mitigations.

The National Patient Safety Alert has further information and actions to be complete as soon as possible but no later than 20 November 2026.