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'Risk of Harm': Safety Alert Issued to Healthcare Staff over Patient Allergy Error

NHS England warns of misrecorded penicillin allergy as penicillamine in electronic systems, risking fatal anaphylaxis; about 1% of people have penicillin allergy, NHS says.

  • NHS England's safety unit, with the Royal Pharmaceutical Society and royal colleges, issued a patient safety alert after penicillin allergies were misrecorded as penicillamine in electronic prescribing systems.
  • NHS England issued an alert on penicillin allergy recording errors, prompting primary and secondary care healthcare workers to set up local working groups to review affected records.
  • Clinicians warn the miscode risks severe reactions, noting patients affected by incorrect allergy records face inappropriate prescribing and anaphylaxis, with symptoms from rash to breathing difficulty or collapse.
  • Affected patients may be contacted directly by healthcare professionals, and NHS guidance says patients do not need to take any immediate action themselves.
  • Given about one in 100 people reports a penicillin allergy, and penicillin is found in common antibiotics such as amoxicillin and co-amoxiclav, miscodes risk unsafe prescribing across NHS England patient records.
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england.nhs.uk broke the news in on Thursday, November 20, 2025.
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