ISMP Warns Barcode Scanning Errors Could Cause Medication Mixups Between Generic Kappra and Aleve

Medication safety experts are warning about serious risks that may result from drug barcode scanning, which could result in medication errors if there is a mix up between generic version of the seizure medication Kappra and the painkiller naproxen, which is a generic version of Aleve.

The Institute for Safe Medication Practices (ISMP) issued an alert on May 14, indicating it has recently received reports from two different hospitals that McKesson packaged levetiracetam 250 unit dose blister packages with a barcode that scans as naproxen 500 mg.

Because of the barcode scanning error, one side of the levetiracetam tablet blister pack scans properly, while the barcode on the other side scans as naproxen. The ISMP says a visual inspection reveals the tablets all appear to be levetiracetam and not naproxen, but the package does not scan properly.

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Scanning the mislabeled package may lead to a medication error when using automated medication inventory storage devices or automated dispensing systems.

If scanned when the medication is being administered, this could cause a wrong drug alert which could lead to confusion and treatment delays. It may also cause the system to document the wrong drug was administered, the ISMP warns.

Levetiracetam is an anticonvulsant used to treat seizures in patients with epilepsy. It works to decrease abnormal excitement in the brain. It is sold under brand names like Keppra Xr and Roweepra.

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat fever and pain. It is sold under the brand name Aleve, among others.

Confusing administration of levetiracetam may cause serious harm to patients who have epilepsy and rely on the medication to help reduce their seizures. Additionally, if naproxen is accidentally given to the patient, some patients may experience side effects due to allergy issues.

ISMP officials say they contacted McKesson Packaging about the barcode scanning error problem and were informed the company is conducting an investigation. The ISMP also alerted the Food and Drug Administration (FDA) about the problem.

The barcode scanning problems affects levetiracetam packages with NDC number 63739-10 and the lot number in both cases is 0000124916.

Medication side effects, errors and other dosing problems should be reported to the FDA’s Adverse Event MedWatch program.


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