Action Required: Penicillamine vs. Penicillin Drug Allergy Recording
Cegedim Healthcare Solutions has been made aware of a historical incident where a patient had been incorrectly coded as having a drug allergy to Penicillamine (indicated for rheumatoid arthritis, Wilson’s disease), rather than Penicillin. The patient was prescribed Penicillin, and sadly passed away. A SEA (Significant Event Analysis) was undertaken at the patient's practice to minimise the risk of this happening again. There are existing mitigations in place within the Vision system, including displaying the following NPSA High Risk Process similar name drug warning when a user selects to add a Drug Allergy to Penicillamine or at the point of prescribing this drug:
Note that there is no longer a drug in the dictionary called “Penicillin” and hasn’t been for many years. Quite some time ago these antibiotics were renamed (e.g. Phenoxymethylpenicillin, Benzylpenicillin, etc).
Actions requested to be performed by GP practices:
As additional mitigation against the risk of further instances of occurrence and patient harm, Cegedim Healthcare Solutions requests that all GP practices carry out the following actions.
1. Run the clinical audit that has been produced for use to identify any patients with a penicillamine allergy recorded. This audit is available for download at http://help.visionhealth.co.uk/clinical%20audit/Content/Downloads/INPS%20Daily.htm (see link under Data Quality - Updated 08/12/2022). The reporting lines in this audit are as follows:
2. Where any patients are found with a penicillamine allergy recorded, verify that this is accurate (including checking with the patient, as necessary).
3. For any patients where a penicillamine allergy has been recorded incorrectly and should in fact be recorded as an allergy to a penicillin product (e.g. Phenoxymethylpenicillin, Benzylpenicillin, etc), correct the information recorded in the patient record to accurately reflect their allergy status.
4. Where any patients with a penicillamine allergy incorrectly recorded are found, requiring to be changed to reflect that they in fact have a penicillin allergy, please report to Cegedim Healthcare Solutions by contacting their Clinical Safety Team via clinical.safety@visionhealth.co.uk