Problem
With the United States, Canada, and Mexico hosting the FIFA (Fédération Internationale de Football Association [French] or International Federation of Association Football [English]) World Cup in multiple cities starting this June, and in planning for other upcoming large international events such as the 2028 Summer Olympics in Los Angeles, hospitals (including EDs), urgent care centers, pharmacies, and other healthcare organizations may see an influx of patients who need medications to treat chronic conditions or who require urgent treatment while traveling. International travelers seeking medical care during these large events face increased medication safety risks, which also pose challenges for healthcare organizations within those host cities. Additionally, several states with tourist attractions might experience international travelers regularly visiting the area, so there needs to be consistent processes in place for these potential patients.
Patients may present with both prescription and over-the-counter medications labeled in a different language or with different brand names or generic names, and with drugs and treatment regimens that do not align with hospital or pharmacy formularies and practices within the United States. Vulnerabilities may include the need for translating prescriptions, labels, and medication lists; unfamiliar brand or generic drug names and strengths; look-alike or sound-alike medication names compared to US products; and unfamiliar doses, dosing units, instructions, or formulations. These factors heighten the risk of selection errors, under- or overdosing, and unintentional duplication or omission of therapy. These situations may be particularly challenging when practitioners must make decisions with incomplete or unclear medication information. Community pharmacies must also ensure that patients receive prescription directions, warnings, and counseling in their preferred language.
We have written about similar problems in the past. For example, in our December 3, 2015 article, Same Name, Different Drug Outside US, we shared that a hospital pharmacist received an order for “Cartia 100 mg” along with instructions stating that the patient would bring in their own medication. The pharmacist assumed that the patient would be taking CARTIA XT (dilTIAZem), which did not come in a 100 mg strength. The prescriber insisted that the 100 mg was correct, so the pharmacist followed up when the patient brought the medication into the hospital. It turned out that the medication was actually aspirin, or acetylsalicylic acid, which is available under the brand name Cartia in Israel, the patient’s home country (Figure 1).
Figure 1. In multiple international markets, Cartia is aspirin
Similar to situations that require emergency preparedness (e.g., unanticipated electronic health record [EHR] downtime), preparing for surges of international travelers requires proactive medication safety planning, clearly defined roles, readily available reference tools, and practice drills so staff can safely function when usual safeguards are limited.
Safe Practice Recommendations
Organizations need to establish a consistent process to safeguard medication use for international travelers and should consider the following:
Assess risk before the surge. Engage emergency preparedness teams and conduct a proactive risk assessment (e.g., failure mode and effects analysis) focused on medication history intake, prescribing, verification, dispensing, administration, and discharge counseling for patients with limited English proficiency (LEP) or whose medication lists may include non-US brand and generic drugs. Focus on high-alert medication scenarios where an error (e.g., name or strength mix-up) may have a higher chance of causing serious harm. Consider vulnerable steps in the medication-use process where interpreter services and additional international drug information resources may be required.
Establish clear roles and escalation pathways. Designate an interdisciplinary response team to develop interim processes when risk is elevated. Define an escalation trigger for pharmacy consultation (e.g., unclear product name or strength, non-English label with no translation services available, suspected therapeutic duplication, high-alert medications). Ensure there is an escalation pathway (e.g., on-call leadership coverage after hours) so frontline staff know who can quickly triage safety issues and mobilize additional resources if needed.
Offer language services. Make formal interpreter services available, including in-person, video call, or via telephone. Avoid using interpretation services from multilingual teammates or family members, who are not professionally trained in healthcare translation.
Document in the EHR and pharmacy dispensing systems. Build required fields to document preferred patient language and interpreter service needs in the EHR. Ensure this information is easily accessible to staff. Hospital and ambulatory care settings should automatically schedule interpreters at clinical points of service for patients who are identified with LEP.
Create a communication “triage” process. Create a policy and procedure for “unknown medication” situations: gather information, engage interpreter services, contact the pharmacy, and document what was verified and how it was verified. Standardize how unclear medication information is communicated and documented in the EHR, including when a practitioner will need further clarification.
Develop an easily accessible medication verification resource. Create a curated packet (electronic and hard copy) that is easy to find, prominently version-dated, and reviewed at least annually. Include a step-by-step guidance for: available resources that can be used for identifying international brand- and generic-named single ingredient and combination products; converting strengths/concentrations; and documenting equivalencies (what was verified, by whom, and which source was used). Focus on any important clinical dosing/monitoring/goal differences for high-alert medication classes (e.g., insulin, antithrombotics) as well as a “crosswalk” for common generic/brand names. List internal and external resources with phone numbers/workflows. This may include interpreter services, toxicology/poison centers, and medication databases (e.g., Lexidrug, Micromedex) that provide international drug information.
Strengthen medication reconciliation for international travelers. Request original medication containers, photos of labels, and a written medication list when available. Use qualified medical interpreters to obtain a medication history. Build in a “two-source verification” expectation for high-alert medications (e.g., label/photo plus a trusted drug information source; or patient’s container plus pharmacist verification). When substitution to a US drug is needed, include the indication in the order and provide education before starting the medication and prior to discharge to ensure patient understanding, and to prevent duplication when the patient resumes their usual home medications.
Collaborate with community pharmacies. When proactively planning for an international travel surge, hospitals and clinics should reach out to local community pharmacies to collaborate. Notify them of the steps your organization has taken and communicate identified risks and mitigation strategies. Community pharmacies should complete similar risk assessments to ensure there is a standard process for medication labeling, translation, and interpreter services. In addition, community pharmacies should consider flagging these prescriptions in their system to ensure patient counseling is done and in the patient’s preferred language.
Educate staff and improve after each event. Provide just-in-time refreshers before major events, focusing on units that may be most impacted (e.g., admissions, ED, inpatient units, inpatient and outpatient pharmacy), on how to access interpreter services and the medication verification resource packet, and when to escalate to leadership. Run brief tabletop exercises or simulations using realistic “international label” and “unfamiliar brand name” scenarios to practice the workflow and identify gaps in the process. After the event surge, review safety concerns, including delays, close calls, and errors. Update tools/forms and share lessons learned with frontline teams to continuously improve the process.
Engage and educate patients. During discharge counseling and community pharmacy dispensing, ensure interpreter services are available if needed, implement the teach-back method, and have patients show and tell how they plan to take their medications. Avoid closed-ended questions and never assume patients understand how to take their medications. Emphasize if a new drug replaces a home medication, whether the home medication should be resumed or stopped after discharge or upon return to their home country, and how to avoid unintentional duplication when returning to the usual home medication. Share resources such as those found on the ISMP consumer website, Medicine Safety Tips While Traveling.
We thank Donald McKaig, RPh, from Brown University Health, for helping to write this article.
