National Patient Safety Alert – NatPSA/2025/006/NHSPS
Published on 20 November 2025
From: NHSScotland Assure
NatPSA/2025/006/NHSPS - Harm from incorrect recording of a penicillin allergy as a penicillamine allergy
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There are reports of healthcare staff recording a patient’s penicillin allergy as a penicillamine allergy in electronic prescribing systems. This look-alike sound-alike error risks a patient with a known penicillin allergy being administered a penicillin based antibiotic and having a potentially fatal anaphylactic reaction.