From the October 2008 issue

Sanofi-aventis is distributing a letter to pharmacists regarding the risk of mix-ups between its CARAC (fluorouracil) cream (0.5%), used for the topical treatment of multiple actinic or solar keratoses of the face and anterior scalp, and Altana’s KURIC (ketoconazole) cream (2%), used for the topical treatment of fungal infections and seborrheic dermatitis. The letter provides details about a dispensing error caused by an improperly transcribed verbal order for Kuric, which was misheard as Carac and dispensed to a patient. The patient developed a severe rash with erythema, irritation, peeling of the skin, and secondary infection involving the application site and surrounding areas following the dispensing error. Sanofi-aventis has suggested precautions to prevent this mix-up, including clarification of oral and written orders, verification of the brand and generic names, spelling the product name when reading back oral orders, matching the product’s indication to the patient’s condition, and drawing attention to the differences in the names of these products. Please visit www.ismp.org/docs/CaracLetter20080110.pdf to view the letter.