ISMP Special Alerts

Barcode Scanning Error

ISMP has received reports from two different hospitals about McKesson packaged levetiracetam 250 unit dose blister packages that have a barcode that scans as naproxen 500 mg. Apparently one side of the unit dose blister of 10 levetiracetam tablets scans properly, but the barcode on other side indicates that the blister contains naproxen 500 mg. The NDC number is 63739-795-10.  The lot number in both cases is 0000124916.

Based on visual inspection of the tablet and imprint code, the tablets contained in the blister pack all appear to be levetiracetam 250 mg. 

ISMP has been in touch with McKesson Packaging and they are investigating. ISMP has also alerted the US Food and Drug Administration.

Scanning the mislabeled package may lead to a misfill when using automated medication inventory storage devices or automated dispensing systems, and may ultimately contribute to a wrong drug error. If scanned during medication administration, it could generate a wrong drug alert which could lead to confusion and treatment delays or it might document administration of the wrong drug.

barcode scanning error


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