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Reporting a Medication Error

International drugs may have same name but different uses

4b0a3f295543bcdb7e84aacab1169fb5 MMany people rely on prescription and/or over-the-counter (OTC) medicines to treat an array of conditions. When traveling, either for business or leisure, that doesn’t change. So, if you will be traveling outside your home country, there is something important you need to know about medicines. The country you are traveling to may have the same brand name medicine available but it may actually contain a different ingredient that is used to treat a different condition.

An example of this problem was identified in a recent medication error report we received. A man traveling to the United States from his home country of Israel needed to be hospitalized. The hospital pharmacist received an order for “Cartia 100 mg” and was notified that the man would be bringing his own medication. The pharmacist questioned the doctor about the dose of 100 mg that was ordered. The pharmacist assumed the prescription was for Cartia XT (diltiazem extended release), a medicine used commonly in the United States (Figure 1). However, Cartia XT is available in only 120 mg, 180 mg, 240 mg, and 300 mg strengths. However, the doctor insisted the dose was 100 mg.


When the man arrived at the hospital, the pharmacist asked to see his medicine that he brought into the hospital. It turned out that the medicine was actually aspirin, or acetyl salicylic acid, which is available under the brand name Cartia in Israel, the patient’s home country (Figure 2).


This is not the first time we have written about international medicines which share a brand name but contain totally different ingredients. In 2012, we posted an article about an American man who ran out of his medicine while traveling to Serbia. The medicine he ran out of was called Dilacor XR (diltiazem extended-release). However, the Serbian pharmacist refilled the prescription with the Serbian brand name medicine called Dilacor. In Serbia, Dilacor is the brand name for digoxin, a totally different medicine than diltiazem. Digoxin is used to lower the heart rate while diltiazem is used to lower blood pressure.

These two cases serve as excellent examples of the importance of carrying a medication list that includes both the generic and brand names when you travel. In the event you need a temporary supply of medicine while overseas, it is important to make sure the correct medicine has been dispensed since brand name products may contain different active ingredients in different countries.

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