National patient safety alert – harm from incorrect recording of penicillin allergy as penicillamine allergy
In a significant move to enhance patient safety, NHS England’s National Patient Safety team has issued a joint alert in collaboration with several key medical organizations, including the Royal Pharmaceutical Society, Royal College of Physicians, and Royal College of General Practitioners. The alert addresses a critical risk associated with electronic prescribing and medicines administration (EPMA) systems, specifically the potential for healthcare professionals to mistakenly record patients’ penicillin allergies as penicillamine allergies. This misclassification can lead to severe consequences for patients, as it may result in inappropriate prescribing practices and adverse drug reactions.
Penicillin and penicillamine, though similar in name, are entirely different medications with distinct uses and implications for patient health. Penicillin is a widely used antibiotic critical for treating various bacterial infections, while penicillamine is primarily used in the management of conditions such as rheumatoid arthritis and Wilson’s disease. The confusion between these two medications can arise due to the similarity in their names, particularly in electronic health records where typographical errors or misinterpretations can occur. The alert emphasizes the importance of accurately documenting and communicating patients’ allergies to prevent harmful prescribing errors.
To mitigate this risk, the alert encourages healthcare providers to adopt best practices in documenting allergies, including double-checking entries in electronic systems and ensuring clarity when discussing patient allergies. Additionally, the alert serves as a reminder of the broader implications of electronic prescribing systems, highlighting the need for ongoing training and vigilance among healthcare professionals. By raising awareness and promoting accurate documentation, the NHS aims to safeguard patient health and improve overall safety within healthcare settings, ultimately reducing the likelihood of adverse drug events related to allergy misrecording.
A joint National Patient Safety Alert has been issued by the NHS England National Patient Safety team, in collaboration with the Royal Pharmaceutical Society, Royal College of Physicians and Royal College of General Practitioners, about the risk of harm from inadvertently recording patients’ penicillin allergies as penicillamine allergies in electronic prescribing and medicines administration (EPMA) […]
