A critical national patient safety alert has been issued to all healthcare staff across England following disturbing reports of patient penicillin allergies being incorrectly recorded in medical systems.
What is the nature of the error?
The alert, published on 20th November 2025, was issued by the NHS England National Patient Safety team in collaboration with major medical bodies, including the Royal Pharmaceutical Society, Royal College of Physicians, and Royal College of General Practitioners. The investigation found that in electronic prescribing systems, a patient's known penicillin allergy was being wrongly recorded as an allergy to penicillamine.
This is a significant and dangerous mistake. Penicillin is a common antibiotic found in medicines like Amoxicillin and Flucloxacillin, used to fight infections. Penicillamine, however, is a completely different drug used to treat conditions like Wilson's disease and severe rheumatoid arthritis.
What are the potential consequences?
The implications of this recording error are severe. If a patient with a true penicillin allergy is prescribed a penicillin-based antibiotic, they could suffer a potentially fatal anaphylactic reaction.
Anaphylaxis is a medical emergency. Symptoms can develop within minutes and include a widespread itchy rash, difficulty breathing, swelling, and collapse. With approximately one in 100 people having a penicillin allergy, the scale of the risk is considerable.
What action is being taken?
In response, primary and secondary care healthcare workers have been instructed to establish working groups to identify and review the records of those who may be affected by this error.
The alert reinforces that healthcare staff must always check a patient's allergy status before prescribing or administering any medication as a fundamental part of routine safety procedures.
For the public, the message is clear: patients do not need to take any immediate action. If your records are involved, you may be contacted directly by a healthcare professional. If you have any concerns about medication you have been prescribed, you should contact your GP or local pharmacy for support and information.
