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NHS England (NHSE) has urged community pharmacies to be vigilant after reports emerged that patients’ penicillin allergies have been mistakenly recorded as ‘penicillamine’ in electronic prescribing systems, leading to the death of one individual.

A three-year review of national incident data revealed a patient died from an anaphylactic reaction to a penicillin-based antibiotic after they were inadvertently prescribed the antibiotic. Their allergy to penicillin was recorded as “penicillamine allergy” on their GP record.

Penicillamine is a drug used to treat Wilson’s disease and severe active rheumatoid arthritis.

A warning about the risk of harm the look-alike sound-alike error poses was issued in safety alert by NHSE in collaboration with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners.

NHSE said the risk of error was “not specific to any one electronic prescribing system” and occurs because the allergy page displays drugs by drug name or group, and since penicillin is a drug group, it does not appear as an option in the ‘drug name’ search. Penicillamine is the only option when ‘penicill’ is the search term.

Risk of error also arises because in the alphabetical drop-down list of both drug names and groups, penicillamine comes above penicillin.

Identify patients recorded as having a penicillamine allergy

The alert was aimed at acute, community and mental health providers, health and justice services and primary care including nursing and care homes, general practice and community pharmacy.

NHSE urged primary and secondary care organisations to form a working group “across an appropriate geographical area” which should be chaired by “an appropriate chief clinical information officer” to identify patients recorded as having a penicillamine allergy.

NHSE said the group should review and correct allergy records, put in place additional safeguards in training and processes and work with digital system suppliers to develop “technical mitigations” within 12 months.

Primary care staff were told to implement additional checks when staff, especially non-clinical team members, input allergy status into GP systems. “For example, consider the need for a clinical review if penicillamine is the stated allergen,” NHSE said.

It revealed all the other penicillin-penicillamine incidents were recorded as “low or no harm” thanks to healthcare staff identifying the error before it “became clinically significant”.