GPs asked to review patients after potentially fatal mistakes in penicillin allergy records

Primary care teams are being asked to review medical records after a critical safety alert from NHS England warned of a ‘significant number’ of patients with a penicillin allergy wrongly recorded.

It follows reports of healthcare staff recording a patient’s penicillin allergy as a penicillamine allergy in electronic prescribing systems because the wrong option has been clicked on the dropdown menu.

One nursing home patient had died after inadvertently prescribed penicillin because their known allergy had been recorded as penicillamine allergy on their GP record, a three-year review of national incidents found.

‘Initial enquiries’ have identified ‘significant numbers of patients’ with a recorded penicillamine allergy status in both primary and secondary care, ‘which would appear to be inaccurate given the known prevalence of allergy to penicillamine’, the alert said.

An error in recording the correct allergy in one setting can then spread through shared patient records, NHS England warned.

The ‘look-alike, sound-alike error’ is not specific to any one electronic prescribing system and can happen for two reasons:

• If a system only displays by name rather than drug group, penicillamine will be the only option presented when ‘penicill’ is the search term.
• In an alphabetical drop-down list of drug names and groups, penicillamine comes above penicillin.

There had been other incidents, that included patients having side effects or penicillin being incorrectly prescribed, but in those cases healthcare staff had identified the issue before it became clinically significant, NHS England said.

Working groups will now be set up in ICB regions to co-ordinate the identification of potential errors in GP and hospital records.

All patients with a record of penicillamine allergy will need to be reviewed clinically to see if it is accurate and all systems updated.

This is because there may be a minority of patients may have a genuine allergy to penicillamine, NHS England said.

Primary care teams should also implement additional checks when staff ‘especially non-clinical staff’ input allergy status into GP systems.

This should include considering the need for a clinical review if penicillamine is the stated allergen, the alert said.

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.

This could include a warning added to local systems on selection of penicillamine allergy to ensure a mistake has not been made.

‘Discussions at a national level are ongoing with suppliers of electronic prescribing systems to improve allergy functionality and warning alerts,’ NHS England said.

The working groups should produce regular reports on allergy status until ‘assurance has been gained that the issue is resolved’.

‘Ideally, primary and secondary care should collaborate to review the accuracy of recorded allergy status, to avoid patients being contacted multiple times and to ensure changes to records are replicated across care settings,’ the guidance noted.

The actions should be completed as soon as possible but no later than November 2026, the alert said.

Around 6% of people’s records carry a penicillin allergy label but up to 90-95% of these labels are thought to be inaccurate because the patient has reported being intolerant, such as feeling nauseous but does not have an anaphylactic reaction.