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Practitioners' Reporting NewsIs That A Letter "C" Or An "E"?Issued May 28, 2004 USP's Medication Errors Reporting Program received a report from a pharmacist regarding the imprint code on Ranbaxy's buspirone (antianxiety agent). At the pharmacist's facility, the pharmacist is responsible for identifying the patient's home medications prior to their administration to the patient. A patient brought in a bottle labeled buspirone 10 mg tablets, manufactured by Ranbaxy, with instructions to take six (6) tablets nightly. The tablet in the bottle was round, white, scored, and had an imprint that looked like a letter "E" over the numbers "152." Based on this information, the pharmacist tried to confirm the medication using the Ident-A-Drug reference, but discovered that the tablet imprint code indicated it was Eon's lisinopril/hydrochlorothiazide 20 mg/12.5 mg (antihypertensive agent). The patient's blood pressure was low, so there was concern that the patient may not be receiving the correct medication. Upon further investigation and a call to Ranbaxy, it was determined that the buspirone was actually imprinted with the symbol " This example illustrates the confusion that can result when trying to identify or confirm products. If your facility stocks these two manufacturer's products, be sure to take measures to prevent mix ups by placing alert stickers on the bottles. It may also be necessary to notify patients and family members or caregivers who are taking or administering Ranbaxy's buspirone that the imprint on the tablet is a symbol " 
Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices. |
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Copyright © 2010 The United States Pharmacopeial Convention
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" (a letter "C" with a dash in the middle) over the numbers "152," rather than a letter "E" over the numbers "152." Essentially, the patient was receiving the correct medication, but it was difficult to confirm this information due to the difficulty deciphering the symbol imprinted as part of the manufacturer's code.