A JOINT National Patient Safety Alert has been issued after healthcare providers across England reported cases in which patients’ penicillin allergies were incorrectly recorded as penicillamine allergies in electronic prescribing and medicines administration systems. NHS England, working with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners, warns that this documentation error could expose patients with confirmed penicillin allergy to penicillin-based antibiotics, creating the potential for life-threatening anaphylaxis.
Alert Highlights Drug Name Confusion Risks
Although the two drugs sound similar, their clinical uses differ entirely. Penicillin refers to a broad class of antibiotics widely used in acute and primary care settings. Penicillamine, by contrast, is a disease-modifying agent used in Wilson’s disease and severe rheumatoid arthritis. Because the medications appear close alphabetically and share phonetic similarities, the alert notes that transcription and selection errors in busy clinical environments have occurred repeatedly across electronic prescribing systems.
The new alert requires all primary and secondary care organisations to form working groups to identify any patients affected by incorrect allergy entries and conduct clinical reviews to amend the records. Organisations are also instructed to strengthen staff training, introduce additional checking processes and work with digital system suppliers to embed technical safeguards that reduce the risk of future mis-entries. All mandated actions must be completed within twelve months under executive oversight.
Clinical Checks and Regulatory Responsibilities
NHS England stresses that patients do not need to take any immediate action, but clinicians must continue to verify allergy status before prescribing or administering medicines. Affected patients may be contacted directly by healthcare teams. The alert reminds providers that failure to act on National Patient Safety Alerts may lead to regulatory action by the Care Quality Commission.
Reference
National Health Service (NHS) England. National patient safety alert – harm from incorrect recording of penicillin allergy as penicillamine allergy. 2025. Available at: https://www.england.nhs.uk/. Last accessed: 1 December 2025.
