Key Summary
- Penicillin–penicillamine mix-ups are causing dangerous prescribing errors
- NHS orders organisations to find and fix incorrect allergy records and add safety safeguards
- Staff told to always double-check allergy status
A safety alert has been issued about the risk of harm from inadvertently recording patients’ penicillin allergies as penicillamine allergies in electronic prescribing and medicines administration (EPMA) systems.
The warning has been issued jointly by the NHS England National Patient Safety team, the Royal Pharmaceutical Society (RPS), Royal College of Physicians and Royal College of General Practitioners.
‘Penicillin’ describes a group of broad-spectrum penicillin-based antibiotics, whereas penicillamine is used to treat Wilson’s disease and severe rheumatoid arthritis.
There have been incidents where healthcare staff have incorrectly recorded the allergy, and this mix-up is leading to wrong antibiotic administration, which could cause a lethal anaphylactic reaction for the patients.
The alert is meant for primary and secondary care organisations to find affected patients, fix incorrect allergy records, add extra safety checks in training and workflows, and work with IT suppliers to improve system safeguards within a year.
Healthcare staff have been advised to check a patient’s allergy status before prescribing or administering medication as part of routine safety procedures.
