Patient death from penicillin allergy error triggers records review

Credit: Getty/RapidEye

By Emma Wilkinson

Clinicians have been asked to review patient records after NHS England found potentially fatal errors in how a medicines allergy is documented.

At least one patient has died after having their known penicillin allergy recorded on their record as an allergy to rheumatoid arthritis drug, penicillamine.

The nursing home resident had been given penicillin for an infection and had died after an anaphylactic reaction.

A three-year review had identified 315 patient safety incidents related to the mix up which happens because the wrong drug had been clicked on the drop-down menu.

The National Patient Safety Alert said “initial enquiries” had identified significant numbers of patients with a recorded penicillamine allergy status across primary and secondary care, “which would appear to be inaccurate given the known prevalence of allergy to penicillamine”.

An error in recording a penicillin allergy in one setting can easily spread through shared patient records, NHS England added.