International Journal of Clinical Pharmacy

, Volume 35, Issue 1, pp 72–78 | Cite as

What do hospital staff in the UK think are the causes of penicillin medication errors?

  • Michael WilcockEmail author
  • Geoff Harding
  • Lorraine Moore
  • Ian Nicholls
  • Neil Powell
  • Jon Stratton
Research Article


Background Medication errors are a potential major threat to patient’s health, and allergic reactions occurring in patients with known allergies are an important preventable form of adverse drug event. The use of penicillin antibiotics in patients who are allergic to penicillin, in particular, is a major concern. Aim To survey staff attitudes and beliefs to incidents involving penicillin allergic patients who are prescribed and administered penicillin antibiotics. Setting A 650 bed teaching hospital in England. Method Using individual and (focus) group interview proceedings with a purposive sample of doctors, nurses and pharmacists, an electronic questionnaire was administered hospital wide to all clinical staff. No reminders were issued. Main outcome measures: Clinical staff’s views on the causes of penicillin medication errors. Results The electronic survey was completed by 235 members of the clinical staff. Half the respondents definitely considered themselves knowledgeable about which antibiotics contain penicillin medicines, though approximately 90 % of respondents considered that misinformation or lack of knowledge on which antibiotics contain penicillin medicines was an issue for some or most colleagues. Various organisational issues such as the use of red wrist bands, the wearing of red tabards by the nurse during the medicines round, and a busy work environment were recurrently highlighted as systems factors that could be improved upon. Conclusion Our study elucidated concerns amongst clinical staff relating to the scenario of a penicillin allergic patient receiving a penicillin antibiotic. The resulting local learning and feedback about staff beliefs pertaining to this one specific type of error will be used to consider the nature and type of local action to be taken to help improve patient safety.


Allergy Education England Hospital Medicines administration Penicillin Pharmacist 



The authors would like to thank those hospital staff who participated in the various aspects of this study.


Pfizer, through an educational grant, helped facilitate some aspects of the qualitative work described.

Conflicts of interest

No conflicts of interest to declare.


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Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Michael Wilcock
    • 1
    Email author
  • Geoff Harding
    • 2
  • Lorraine Moore
    • 1
  • Ian Nicholls
    • 1
  • Neil Powell
    • 1
  • Jon Stratton
    • 3
  1. 1.Pharmacy DepartmentRoyal Cornwall Hospitals NHS TrustTruroUK
  2. 2.Primary CarePeninsula College of Medicine and DentistryExeterUK
  3. 3.Royal Cornwall Hospitals NHS TrustTruroUK

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