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Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters

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About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation. To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation. During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence. Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media. Errors in medical interpretation are common, averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.
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Errors in Medical Interpretation and Their Potential Clinical
Consequences in Pediatric Encounters
Glenn Flores, MD*; M. Barton Laws, PhD; Sandra J. Mayo, EdM; Barry Zuckerman, MD‡;
Milagros Abreu, MD*‡; Leonardo Medina, MD‡; and Eric J. Hardt, MD§
ABSTRACT. Background. About 19 million people in
the United States are limited in English proficiency, but
little is known about the frequency and potential clinical
consequences of errors in medical interpretation.
Objectives. To determine the frequency, categories,
and potential clinical consequences of errors in medical
interpretation.
Methods. During a 7-month period, we audiotaped
and transcribed pediatric encounters in a hospital outpa-
tient clinic in which a Spanish interpreter was used. For
each transcript, we categorized each error in medical
interpretation and determined whether errors had a po-
tential clinical consequence.
Results. Thirteen encounters yielded 474 pages of
transcripts. Professional hospital interpreters were
present for 6 encounters; ad hoc interpreters included
nurses, social workers, and an 11-year-old sibling. Three
hundred ninety-six interpreter errors were noted, with a
mean of 31 per encounter. The most common error type
was omission (52%), followed by false fluency (16%),
substitution (13%), editorialization (10%), and addition
(8%). Sixty-three percent of all errors had potential clin-
ical consequences, with a mean of 19 per encounter.
Errors committed by ad hoc interpreters were signifi-
cantly more likely to be errors of potential clinical con-
sequence than those committed by hospital interpreters
(77% vs 53%). Errors of clinical consequence included:
1) omitting questions about drug allergies; 2) omitting
instructions on the dose, frequency, and duration of an-
tibiotics and rehydration fluids; 3) adding that hydrocor-
tisone cream must be applied to the entire body, instead
of only to facial rash; 4) instructing a mother not to
answer personal questions; 5) omitting that a child was
already swabbed for a stool culture; and 6) instructing a
mother to put amoxicillin in both ears for treatment of
otitis media.
Conclusions. Errors in medical interpretation are com-
mon, averaging 31 per clinical encounter, and omissions are
the most frequent type. Most errors have potential clinical
consequences, and those committed by ad hoc interpreters
are significantly more likely to have potential clinical
consequences than those committed by hospital inter-
preters. Because errors by ad hoc interpreters are more
likely to have potential clinical consequences, third-party
reimbursement for trained interpreter services should be
considered for patients with limited English proficiency.
Pediatrics 2003;111:6–14; language, interpreters, medical
errors, children, pediatrics, Hispanic Americans, quality.
ABBREVIATIONS. LEP, limited in English proficiency; SD, stan-
dard deviation.
According to the 2000 census, 45 million peo-
ple in the United States speak a language
other than English at home, and 19 million
are limited in English proficiency (LEP).
1
Five per-
cent of school-aged US children (or 2.4 million) are
LEP, an 85% increase since 1979.
2
Language barriers
affect multiple aspects of health care for the LEP
patient, including access to care, health status, and
use of health services.
3
Studies document that LEP
patients often defer needed medical care,
4
have a
higher risk of leaving the hospital against medical
advice,
5
are less likely to have a regular health care
provider,
6
and are more likely to miss follow-up
appointments,
7
to be nonadherent with medica-
tions,
7
and to be in fair/poor health.
6
A medical interpreter is an essential component of
effective communication between the LEP patient
and the health care provider. Medical interpreters
may be professional hospital interpreters employed
by a health care institution, or ad hoc, untrained
individuals, such as family members, friends, non-
clinical hospital employees, and strangers from wait-
ing rooms. Previous work has shown that family
members
8
and untrained bilingual nurses
9
who pro-
vide ad hoc interpretation can commit many errors
of interpretation. Not enough is known, however,
about the frequency and categories of medical inter-
preter errors that occur in clinical encounters,
whether such errors potentially have clinical conse-
quences, and if the use of hospital rather than ad hoc
interpreters produces a higher quality of medical
interpretation. The goals of this study, therefore,
were to: 1) determine the frequency, categories, and
potential clinical consequences of errors committed
by medical interpreters; and 2) compare the quality
of interpretation by professional hospital versus ad
hoc interpreters.
METHODS
We audiotaped pediatric encounters in which a Spanish inter-
preter was used in the pediatric outpatient clinic of an urban
From the *Center for the Advancement of Urban Children, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; Depart-
ments of ‡Pediatrics and §Internal Medicine, Boston University School of
Medicine, Boston, Massachusetts; and Latino Health Institute, Boston, Mas-
sachusetts.
Presented in part at the annual meeting of the Pediatric Academic Societies;
May 2, 1999; San Francisco, CA.
Received for publication Jan 29, 2002; accepted May 24, 2002.
Reprint requests to (G.F.) Center for the Advancement of Urban Children,
Department of Pediatrics, 8701 Watertown Plank Road, Milwaukee, WI
53226. E-mail: gflores@mail.mcw.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
6PEDIATRICS Vol. 111 No. 1 January 2003
Massachusetts hospital over a 7-month period. All study parents
had identified themselves as LEP. A bilingual research assistant
was present during the encounter only to record the interaction,
and did not act as an interpreter, nor take part in subsequent
production of transcripts or data analysis. A bilingual verbatim
transcript was prepared from the audiotape of each encounter by
a professional transcriptionist fluent in both English and Spanish.
To ensure accuracy and reliability of the transcripts, each tran-
script was reviewed 3 times for errors, once by a bilingual physi-
cian whose first language is English (G.F.), a second time by a
bilingual sociologist whose first language is English (M.B.L.), and
a third time by a bilingual physician whose first language is
Spanish (M.A.).
The encounters analyzed for this study represent all pediatric
visits with Spanish interpreters that occurred in a larger study of
patient-physician communication, which consisted of a conve-
nience sample of 153 audiotaped visits in the pediatric outpatient
clinics of an urban Massachusetts hospital. Of the 153 participants
in this larger study, 110 of the children and their families were
Latino. Among these 110 Latino participants, there were 74 moth-
ers/adult caregivers who were LEP, for which 38 visits occurred
in Spanish with Spanish-speaking clinicians, 13 visits included a
Spanish interpreter, and 25 occurred in English without an inter-
preter. Although this larger study used a convenience sample, the
sample was obtained to reflect a reasonable spectrum of outpa-
tient pediatric visits experienced by Latino families, and has no
obvious selection biases other than respondent refusal, which was
rare (only 2 potential subjects refused to participate). Participants
from the larger study were sampled to capture visits from the full
range of daily office hours and all 5 clinic days (Monday-Friday)
during the work week. Pediatric encounters included walk-in,
sick, and routine health care maintenance visits at the pediatric
primary care clinic, and initial and follow-up visits at the outpa-
tient lead and failure-to-thrive clinics. Both pediatricians and pe-
diatric nurse practitioners provided care to study patients, and
patient care was in no way altered by the study, except for the
presence of the research assistant and tape recorder. The patients
and their families, clinicians, and interpreters were told only that
this was a study of patient-physician communication, and they
were not aware that errors of medical interpretation would be
analyzed.
Personnel who provided medical interpretation were classified
as: 1) hospital interpreters, professional interpreters (ie, those re-
ceiving financial compensation) employed by the study hospitals
department of interpreter services; and 2) ad hoc interpreters, who
could include family members, friends, nonclinical hospital em-
ployees, strangers from waiting rooms, and hospital clinical staff
(including nurses and social workers) who had received no formal
medical interpreter training or screening. During the period when
the study was conducted, all Spanish hospital interpreters who
had been hired had undergone some level of screening and eval-
uation for language proficiency in Spanish and English. There
was, however, no ongoing training or formal performance evalu-
ation in the hospital for interpreters. Low-intensity, voluntary
formal interpreter training was sporadically available at various
community sites, but it was not known what proportion of inter-
preters took advantage of these voluntary community opportuni-
ties.
For each audiotaped encounter, analysis consisted of identifi-
cation of the frequency and categories of interpreter errors. An
interpreter errorwas defined as any misinterpretation of an
utterance that occurred in the clinical encounter, including those
committed by the designated medical interpreter, as well as those
made by health care providers (such as when a physician with
limited Spanish proficiency made errors in Spanish while talking
to the mother after the designated interpreter had departed).
Errors by health care providers were classified as interpreter er-
rors because the study focus was on errors of interpretation made
by any staff member acting as a medical interpreter during a
clinical encounter, and we found that certain providers often
would attempt to interpret when the designated medical inter-
preter departed or was temporarily unavailable.
Five categories were used to classify interpreter errors, based
on 4 categories used in previous work,
10,11
supplemented by an
additional category (false fluency). These categories are as follows:
Omission: The interpreter did not interpret a word/phrase
uttered by the clinician, parent, or child.
Addition: The interpreter added a word/phrase to the inter-
pretation that was not uttered by the clinician, parent, or child.
Substitution: The interpreter substituted a word/phrase for a
different word/phrase uttered by the clinician, parent, or child.
Editorialization: The interpreter provided his or her own per-
sonal views as the interpretation of a word/phrase uttered by the
clinician, parent, or child.
False Fluency: The interpreter used an incorrect word/phrase,
or word/phrase that does not exist in that particular language.
In addition to being classified into 1 of these 5 categories, an
interpreter error was also considered to have potential clinical
consequences if it altered or potentially altered 1 or more of the
following: 1) the history of present illness; 2) the past medical
history; 3) diagnostic or therapeutic interventions; 4) parental
understanding of the childs medical condition; or 5) plans for
future medical visits (including follow-up visits and specialty
referrals).
Medical jargon, idiomatic expressions, and contextual clarifica-
tions may occasionally require medical interpreters to not inter-
pret a phrase word-for-word. Thus, any deviations from word-
for-word interpretation in transcripts that were attributable to
jargon, idioms, or contextual clarifications were not classified as
interpreter errors. Because medical interpreters may also act as a
cultural broker or advocate, any utterances that could be inter-
preted as cultural explanations or patient or family advocacy were
not classified as interpreter errors. A separate analysis of the
relationship of the number of verbal exchanges, the interlocutor,
and the quality of the interpretation will be reported elsewhere in
a separate paper.
The validity of the analytic method for identification and clas-
sification of interpreter errors was assessed as follows: 2 tran-
scripts (cases 26 and 153) were first subjected to preliminary error
analysis using simple definitions of each error type and category.
The 2 transcripts were scored by 3 observers, a bilingual physician
whose first language is English (G.F.) and 2 bilingual physicians
(M.A. and L.M.) whose first language is Spanish. To avoid the
introduction of bias, the latter 2 observers were blinded to the
study goals and hypotheses. Each of the observers was assessed as
being highly fluent in their second language based on years of
experience providing primary care to Spanish-speaking patients
in a Pediatric Latino Clinic (G.F.), 7 years as a research associate on
studies of English-speaking populations in the United States
(M.A.), and years of teaching high school to English-speaking
students in the Massachusetts school system (L.M.). Interobserver
variability for the 3 observers was assessed using agreement ma-
trices and by calculating the percentage of agreement in 2 separate
analyses, 1 for overall interpreter errors, and the second only for
errors of potential clinical consequence. The Kappa Index was also
determined for errors of clinical consequence. It was not possible
to derive a Kappa Index for overall errors, as transcripts could not
be accurately scored for 1 of the 4 cells (cell d): when neither
observer identified an error, there was no reliable way to deter-
mine whether one should count by words, phrases, transcript
lines, or utterances.
The preliminary error analysis of the 2 test transcripts revealed
a mean percentage of agreement (standard deviation [SD])
among the 3 observers on the overall errors of 60% 19, with a
range of 31% to 82%. Disagreements were primarily attributable to
either overlooked errors or unintended differences in the line
numbering of the transcripts analyzed by different observers.
After line numbering corrections, refinements, and meeting for
consensus purposes, there was complete agreement among the 3
observers on the number and type of overall interpreter errors.
The mean percentage of agreement (SD) among the 3 observers
on errors of potential clinical consequence in the preliminary
analysis was 83% 12, with a range of 72% to 97%. The mean
(SD) for errors of potential clinical consequence in the prelim-
inary analysis was 0.57 0.3 (considered a moderate strength of
agreement by the guidelines of Landis and Koch
12
), with a range
of 0.21 to 0.97 (from fair to almost perfect agreement by the Landis
and Koch guidelines
12
). Because the mean percentage of agree-
ment and
were considered unacceptably low, the error catego-
ries and types were further refined. After refinement, there was
mean agreement of 99% 1.7 (range: 97%100%) and a mean
of
0.99 0.03 (range: 0.941.0 [almost perfect by the Landis and
Koch guidelines
12
for both the mean and range]) regarding inter-
preter errors of potential clinical consequence on the 2 test tran-
scripts. The remaining 11 transcripts were analyzed by the first
ARTICLES 7
author, using the refined error categories, types, and analytic
approaches.
To analyze the statistical significance of differences between
hospital and ad hoc interpreters in the proportion of errors made,
the Yates-corrected
2
test was used, with P.05 considered
statistically significant.
Institutional review board approval was obtained from the
participating institution to conduct this study, and written in-
formed consent was obtained from each participating parent.
RESULTS
Thirteen clinical encounters with Spanish inter-
preters present were audiotaped, yielding 6 hours of
audiotapes, 474 pages of transcripts, and 49 513
words that were exchanged. Hospital interpreters
were present in 6 of 13 encounters; in the remaining
7 encounters, the ad hoc interpreters included a
nurse for 3 encounters, a social worker for 3 encoun-
ters, and an 11-year-old sibling for 1 encounter. The
number of words uttered per encounter averaged
3781, and there was no statistically significant differ-
ence in the mean number of words uttered per en-
counter by interpreter type (mean words uttered
3919 when hospital interpreters were present vs 3663
when ad hoc interpreters were present, with P.5
by the 2-tailed Student ttest). The visit type, clinician
present, patient age, and number of interpreter er-
rors in each clinical encounter are summarized in
Table 1.
There were 396 interpreter errors noted in the 13
clinical encounters (Table 2). The mean number (
standard error) of interpreter errors per clinical en-
counter was 30.5 3.6, with a range of 10 to 60.
There was no statistically significant difference be-
tween hospital and ad hoc interpreters in the mean
number of errors committed per clinical encounter.
The proportions of interpreter errors by category
were: omission, 52%; false fluency, 16%; substitution,
13%; editorialization, 10%; and addition, 8%. There
were no statistically significant differences between
hospital and ad hoc interpreters in the proportion of
errors by specific category (Table 2), except for false
fluency errors, which occurred more often during
encounters with hospital than ad hoc interpreters
(22% vs 9%, P.001). Additional analysis of false
fluency errors occurring in encounters with hospital
interpreters revealed that health care providers made
76% of the false fluency errors, and 58% of these
errors occurred while the interpreter was out of the
room or on the phone, whereas the remaining 42% of
errors were made by the provider without any cor-
rection by the interpreter. Health care providers
were 11 times more likely (relative risk: 11.4; 95%
confidence interval: 1.776.2) to make false fluency
errors when a hospital interpreter was involved,
committing 76% of the false fluency errors with
trained interpreters, compared with only 7% of false
fluency errors when untrained interpreters were in-
TABLE 1. Selected Features of Study Encounters
Case Visit Type Clinician Present
Patients
Age
Interpreter
Type
Interpreters
Relationship to
Patient, if Ad Hoc
Interpreter
No. of
Interpreter
Errors in
Encounter
No. (%) of
Interpreter Errors
of Potential
Clinical
Consequence in
Encounter
13 Well-child visit at
pediatric primary
care clinic
Nurse practitioner 7 y Hospital 45 16 (36%)
19 Sick visit at pediatric
primary care clinic
Attending
pediatrician
9 mo Ad hoc Nurse 10 9 (90%)
24 Sick visit at pediatric
primary care clinic
Nurse practitioner
and attending
pediatrician
1 mo Hospital 44 29 (66%)
26 Sick visit at pediatric
primary care clinic
Pediatric resident 2 y Ad hoc 11-year-old sibling 58 49 (84%)
77 Sick visit at pediatric
primary care clinic
Attending
pediatrician
2 mo Ad hoc Nurse 24 20 (83%)
83 Sick visit at pediatric
primary care clinic
Attending
pediatrician
8 mo Ad hoc Nurse 18 12 (66%)
84 Follow-up at failure
to thrive clinic
Attending
pediatrician
12 mo Ad hoc Social worker 21 13 (62%)
88 Walk-in for
immunizations at
pediatric primary
care clinic
Attending
pediatrician
7 y Hospital 14 5 (36%)
106 Follow-up at failure
to thrive clinic
Attending
pediatrician
11 mo Ad hoc Social worker 24 16 (67%)
120 Follow-up at failure
to thrive clinic
Attending
pediatrician
13 mo Ad hoc Social worker 10 8 (80%)
153 Well-child visit at
pediatric primary
care clinic
Nurse practitioner 5 y Hospital 45 23 (51%)
165 Well-child visit at
pediatric primary
care clinic
Nurse practitioner 7 y Hospital 23 16 (70%)
176 Initial visit to lead
clinic
Attending
pediatrician
18 mo Hospital 60 34 (57%)
8INTERPRETER ERRORS AND THEIR CLINICAL CONSEQUENCES IN PEDIATRICS
volved (P.001). Nevertheless, health care provid-
ers committed only 10% of all errors observed in
this study. About three quarters (73%) of the false
fluency errors committed by hospital interpreters in-
volved medical terminology, including not knowing
the correct Spanish words for level,”“results,and
medicine,and using the Puerto Rican colloquial-
ism for mumps, which could not be understood by a
Central American mother.
There were 250 errors (63% of all errors) that had
potential clinical consequences (Table 2). The mean
number (standard error) of errors with potential
clinical consequences per encounter was 19 3.2,
with a range of 5 to 49. Errors made by ad hoc
interpreters were significantly more likely to have
potential clinical consequences than those made by
hospital interpreters, at 77% vs 53% (P.0001).
When an 11-year-old sibling was used as an inter-
preter, for example, 84% of the 58 errors she commit-
ted had potential clinical consequences, and when an
untrained staff nurse interpreted, 90% of his 10 errors
had potential clinical consequences. Indeed, the low-
est proportion of errors of potential clinical conse-
quence committed by an ad hoc interpreter was 62%.
Interpreter errors of potential clinical consequence
included: 1) omitting questions about drug allergies;
2) omitting key information about the past medical
history (a mothers statement that her child had been
hospitalized at birth for a renal infection); 3) omitting
crucial information about the chief complaint and
other important symptoms (Fig 1); 4) omitting in-
structions about antibiotic dose, frequency, and du-
ration; 5) instructing a mother to give an antibiotic
for 2 instead of 10 days (Fig 2); 6) erroneously adding
that hydrocortisone cream must be applied to an
infants entire body, instead of solely to a facial rash
(Fig 3); 7) telling a mother to give soy formula to her
infant, instead of a physicians instructions to breast-
feed only; 8) omitting instructions on the amount,
frequency, and type of rehydration fluids for gastro-
TABLE 2. Summary of Errors of Medical Interpretation Observed in Clinical Encounters in the Study
Interpreter
Type
No. (%) Errors by Error Category No. (%) Errors
of Potential Clinical
Consequence
Total
Errors
Omission Substitution Addition Editorialization False Fluency
Hospital
(N6)
117 (51%) 27 (12%) 17 (7%) 20 (9%) 50 (22%*) 123 (53%) 231
Ad hoc
(N7)
90 (55%) 26 (16%) 15 (9%) 19 (12%) 15 (9%*) 127 (77%) 165
Totals 207 (52%) 53 (13%) 32 (8%) 39 (10%) 65 (16%) 250 (63%) 396
*P.007 by Yates-corrected
2
test for comparison between hospital versus ad hoc interpreters.
P.001 by Yates-corrected
2
test for comparison between hospital versus ad hoc interpreters.
Fig 1. Multiple omission errors of potential clinical consequence committed by an ad hoc interpreter (the patients 11-year-old sister)
during a sick visit to a pediatrician by a 2-year-old child for vomiting and dehydration (case 26). Note that the pediatrician never receives
a response about how many times the child has vomited before the visit, and the interpreter omits the mothers statements about the
childs ear pain and oral lesion.
ARTICLES 9
enteritis; 9) editorializing to a mother that she should
not answer personal questions asked by her physi-
cian about sexually transmitted diseases and drug
use; 10) explaining that an antibiotic was being pre-
scribed for the flu; 11) omitting a mothers clear
explanation that a child had already been swabbed
rectally for a stool culture; 12) omitting and substi-
tuting for a mothers description of her childs ab-
normal behavioral symptoms (Fig 4); and 13) in-
structing a mother to put oral amoxicillin into her
childs ears to treat otitis media (Fig 5).
DISCUSSION
Implications for Practice, Training, and Research
Errors in medical interpretation were found to be
alarmingly common in this study, averaging 31 per
clinical encounter. In addition, there was no statisti-
cally significant difference between hospital and ad
hoc interpreters in the mean number of errors com-
mitted per encounter. Although errors made by hos-
pital interpreters were significantly less likely to be
of potential clinical consequence than those made by
ad hoc interpreters, over half of hospital interpreter
errors had potential clinical consequences. These
findings support the conclusion that most hospital
interpreters do not receive adequate training at their
institution.
13
Fewer than one fourth of hospitals na-
tionwide provide any training for medical interpret-
ers.
13
Only 14% of US hospitals provide training for
volunteer interpreters, and in half of these hospitals,
the training programs are not mandatory.
13
Even
when hospitals provide training to medical interpret-
ers, the training may be limited to short orientation
sessions or shadowing more seasoned interpreters.
13
Our study findings and these national data suggest
that additional research and policy work is needed to
determine what type of medical interpreter training
is most effective in reducing interpreter errors. Spe-
cific issues that need to be addressed include
whether training of medical interpreters should be
mandatory, and which training approaches are most
effective in eliminating common errors of potential
clinical consequence and in improving accuracy and
understanding medical terminology.
The categories of interpreter errors noted in this
study indicate areas where more training is needed
for medical interpreters. Omissions by far were the
most common type of interpreter error, accounting
for more than half of all errors. This finding suggests
that a principal focus of interpreter training should
be the faithful transmission of each and every utter-
ance by clinicians, patients, and patientsfamilies.
Fig 2. Substitution, addition, and omission errors of potential clinical consequence committed by an ad hoc interpreter during a sick visit
to a pediatrician by a 9-month-old child for fever, vomiting, and a rash (case 19).
10 INTERPRETER ERRORS AND THEIR CLINICAL CONSEQUENCES IN PEDIATRICS
Simultaneous remote or on-site interpretation (as is
done in the United Nations) has the potential to
increase the number of utterances and reduce the
number of errors,
11
but concerns can be raised about
the costs of training and implementation, and diffi-
culties with acceptance by interpreters. Most false
fluency errors committed by hospital interpreters
(73%) involved medical terminology. This finding
indicates that medical interpreter training should in-
clude a detailed review of medical terms, with atten-
tion to linguistic issues such as variation among cul-
tural subsets of a single linguistic group. In addition,
periodic performance evaluation, including monitor-
ing of false fluency errors, may be an important
Fig 3. Multiple errors of omission and substitution of potential clinical consequence committed by a hospital interpreter during a sick
visit to a pediatric nurse practitioner by a 1-month-old male infant for seborrhea and an upper respiratory illness.
Fig 4. Omission and substitution errors of clinical consequence committed by an ad hoc interpreter during an 18-month-old boys visit
to a pediatrician in the lead clinic (case 176).
ARTICLES 11
means of quality improvement for medical inter-
preter services, indicating when additional training
in medical terminology is needed.
The categories of interpreter errors noted in this
study also indicate that more training is needed for
clinicians in the use of medical interpreters. Clini-
cians commit most false fluency errors when the
interpreter leaves the room or is taking a telephone
call, and clinicians are 11 times more likely to make
false fluency errors when hospital interpreters par-
ticipate in the clinical encounter. These findings are
consistent with studies that show that most hospital
staff receive no training on working with interpret-
ers,
13
and most medical schools do not provide ade-
quate instruction on linguistic and cultural issues in
clinical care.
14
For example, only 23% of US hospitals
provide any training for their staff on the use of
medical interpreters, and such training may consist
of nothing more than policies and procedures for
requesting interpreters.
13
These studies and our re-
sults suggest that clinicians should receive skills
training on the proper technique for working with
medical interpreters, especially the risk of false flu-
ency errors associated with clinicians with limited
foreign language fluency. It is recommended that
interchanges between such clinicians and patients
(and their families) in a foreign language should be
limited to when the medical interpreter is present
and not distracted; if such interchanges occur with-
out an interpreter, the clinician should consider re-
peating the interchange when the interpreter is avail-
able once again. The limited foreign language skills
of a clinician can prove to be an asset, however, in
that they can provide a means of verifying the qual-
ity of medical interpretation. For example, if the cli-
nician hears a patient utter a word or phrase that was
not translated by the interpreter, the clinician could
bring this to the interpreters attention, and reempha-
size the importance of faithful message transmission
of each and every utterance. Conversely, because
42% of false fluency errors committed by clinicians
occurred in the presence of an interpreter and went
uncorrected, medical interpreters probably should
be taught that it is reasonable and appropriate to
correct clinician false fluency errors.
Medical Errors and Quality of Care
The study findings suggest that interpreter errors
of potential clinical consequence could be a previ-
ously unrecognized possible root cause of medical
errors. Although a recent Institute of Medicine re-
port
15
has drawn much attention to medical errors,
errors of medical interpretation have not generally
been included in the discussion of sources of medical
errors. In this study, several documented common
mechanisms for medical errors
16,17
were observed
among the interpreter errors of clinical consequence,
including being told to use the wrong dose, fre-
quency, duration or mode of administration of drugs
and other therapeutic interventions, and omitting
relevant clinical information on drug allergies and
the past medical history. These findings suggest that
for LEP patients, providing qualified, trained medi-
cal interpreters may be an important means of reduc-
ing medical errors and improving the quality of
medical care. It also seems reasonable that as part of
ongoing quality improvement efforts, medical insti-
tutions might consider periodically audiotaping or
videotaping a representative subsample of clinical
encounters where medical interpreters are used, to
identify and monitor the overall number and catego-
ries of interpreter errors, the number of interpreter
errors of potential clinical consequence, and medical
errors that result from interpreter errors.
Study Limitations
Several limitations of this study should be noted,
along with their implications for future research. Our
sample size was relatively small; studies of errors of
medical interpretation on a larger scale are needed.
Only 1 observer analyzed 11 of the transcripts, so
interpreter errors potentially may have been missed
that could have been identified had multiple observ-
ers analyzed these transcripts. Single-observer tran-
script analysis was performed, however, only after
refinements of the analytic technique were instituted
as a result of multiple-observer testing and valida-
tion. It also seems unlikely that identification and
inclusion of potentially overlooked errors would
have substantially altered the principal study find-
ings, but additional study of this interpreter error
analytic tool is warranted. This study was limited to
pediatric encounters; similar studies of adult LEP
populations need to be conducted, particularly given
that interpreter errors may have an even greater
effect on adults because of their generally greater
morbidity, comorbidity, and mortality. Similarly, we
examined only outpatient encounters with Spanish
Fig 5. Addition and omission errors of clinical consequence made by an ad hoc interpreter during a visit to a pediatric nurse practitioner
by a 7-year-old-girl diagnosed with otitis media (case 165).
12 INTERPRETER ERRORS AND THEIR CLINICAL CONSEQUENCES IN PEDIATRICS
interpreters, and studies are needed of interpreter
errors and their clinical consequences in other lan-
guages and in the emergency department and inpa-
tient settings. The hospital interpreters in this study
had little to no training (although the study institu-
tion has subsequently initiated extensive training of
their hospital interpreters). Replication of this study
with hospital interpreters who have received exten-
sive, consistent training compared with ad hoc inter-
preters may reveal more substantial differences in
the number and categories of errors. Because LEP
patients who need interpreters sometimes obtain
medical care without interpreters, more research is
needed comparing health care quality and satisfac-
tion with care when LEP patients have trained hos-
pital versus ad hoc versus no interpreters.
Policy Implications
The study finding that errors made by ad hoc
interpreters are significantly more likely to have po-
tential clinical consequencescoupled with a fairly
extensive literature documenting that LEP patients
tend to receive poorer quality medical carewould
seem to constitute a strong argument for third-party
reimbursement for trained medical interpreter ser-
vices. Studies demonstrate a wide range of adverse
effects that limited English proficiency can have on
health and use of health services, including impaired
health status,
6,18
a lower likelihood of having a usual
source of medical care,
6,18,19
lower rates of mammo-
grams, pap smears, and other preventive servic-
es,
20,21
nonadherence with medications,
7
a greater
likelihood of a diagnosis of more severe psychopa-
thology and leaving the hospital against medical ad-
vice among psychiatric patients,
5,22
a lower likeli-
hood of being given a follow-up appointment after
an emergency department visit,
23
an increased risk of
intubation among children with asthma,
24
a greater
risk of hospital admissions among adults,
25
an in-
creased risk of drug complications,
26
longer medical
visits,
27,28
higher resource utilization for diagnostic
testing,
28
lower patient satisfaction,
18,29,30
and im-
paired patient understanding of diagnoses, medica-
tions, and follow-up.
31,32
Latino parents consider the
lack of interpreters and Spanish-speaking staff to be
the greatest barriers to health care for their children,
and 1 out of every 17 parents in one study reported
not bringing their child in for needed medical care
because of these language issues.
4
On the other hand,
recent studies indicate that trained professional med-
ical interpreter services are associated with improve-
ments in the delivery of health care services to LEP
patients,
33
but do not increase the mean duration of
medical visits.
34
The lack of trained hospital interpreters is not un-
common for the millions of LEP patients in the
United States: one study found that no interpreter
was used for 46% of LEP patients, and when an
interpreter was used, 39% had no training.
31
In a
guidance memorandum, the Office of Civil Rights
stated that the denial or delay of medical care for
LEP patients because of language barriers constitutes
a form of discrimination, and requires that any re-
cipient of Medicaid or Medicare must provide ade-
quate language assistance to LEP patients.
35
A Pres-
idential Executive Order also has been issued on
improving access to services for persons with Lim-
ited English Proficiency.
36
Concerns have been
raised by medical associations about physicians hav-
ing to cover the costs of complying with the Office of
Civil Rights guidance memorandum,
37
but the issue
could be resolved by having third-party reimburse-
ment for interpreter services. Although additional
research on the cost effectiveness of third-party re-
imbursement for interpreter services would be help-
ful, mounting evidence suggests that additional
studies of the issue may not be needed, including a
successful $71 million lawsuit over a misinterpreted
word in the emergency department,
38
a report of a
prolonged hospitalization for perforated appendici-
tis that might have been avoided if an interpreter had
been called,
39
and a report of children placed in state
custody for mistaken child abuse because of a mis-
interpreted word and failure to initially call an inter-
preter.
39
Legal liability and medical errors may be
important factors in considering whether investment
in third-party reimbursement of interpreter services
is a reasonable strategy for assuring that LEP pa-
tients receive high-quality, equitable care.
ACKNOWLEDGMENTS
This study was supported in part by the Generalist Physician
Faculty Scholars Program (to Dr Flores), the Minority Medical
Faculty Development Program (to Dr Flores), and the Opening
Doors Program (to Dr Laws) of the Robert Wood Johnson Foun-
dation. Dr Flores is a recipient of an Independent Scientist (K02)
Award from the Agency for Healthcare Research and Quality.
We thank Howard Bauchner and Paul Wise for their comments
on earlier manuscript drafts.
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COLLEGE STUDENTS AND THE INTERNET
The report, ‘The Internet Goes to College: How Students Are Living in the Future
With Today’s Technology,’ was produced by the Pew Internet and American Life
Project in Washington, and provides a snapshot of an emerging young digital class.
One fifth of todays college students began using computers from the ages of 5
to 8, the authors state, and an overwhelming 86% of them had gone online
compared with 59% of the general population; 72% check e-mail messages at least
once a day. . . Nearly 75% of college students say they use the Internet more than
they use the library to look for information; just 9% said they used the library
more.
Schwartz J. New York Times. September 16, 2002
Noted by JFL, MD
14 INTERPRETER ERRORS AND THEIR CLINICAL CONSEQUENCES IN PEDIATRICS
... D'une part, peu importe la région, les écrits recensés indiquent que les minorités linguistiques ont un accès limité aux soins de santé dans leur langue, ce qui pose plusieurs risques pour la qualité et la sécurité des soins reçus (Forgues et al., 2011 ;Pocock, 2019 ; Réseau santé en français Î.-P.-É., 2013 ; Villard, 2018 ;Wilson et al., 2005). Il est maintenant reconnu que, lorsque les services en santé ne sont pas offerts dans la langue officielle minoritaire, cela compromet la sécurité des patients issus des CLOSM puisque les possibilités d'erreurs liées au diagnostic, aux interventions et aux traitements augmentent (Association franco-yukonnaise, 2016 ; Bouchard et Desmeules, 2017 ;Bowen, 2015 ;Flores, 2006 ;Flores et al., 2003 ;H. Gauthier, 2016). ...
... La traduction s'applique à des textes écrits, alors que l'interprétation désigne plutôt la transposition de propos communiqués oralement. L'interprétation peut être réalisée de façon formelle par un professionnel ayant reçu une formation à cette fin ou de façon informelle par des professionnels de la santé ou des membres de la famille, ce qui peut toutefois engendrer des situations problématiques et des contraintes (Bowen, 2015 ;Bowen et Roy, 2010 ;de Moissac et Bowen, 2019 ;Flores et al., 2003 ;Schenker et al., 2007 ;Zanchetta et al., 2012). Par exemple, l'interprétation informelle peut compromettre la confidentialité des informations du patient (Farmanova et al., 2018 ;A. ...
... Previous research has con rmed that medical personnel receive insu cient training on working with interpreters. [15][16][17] Many medical errors are preventable, and it is important for physician trainees at all levels, from intern ...
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Background Pediatric trainees, like other medical professionals, can be held accountable for their actions and may be included in malpractice lawsuits. By understanding the factors that contribute to these cases, it may be possible to identify opportunities for intervention and prevention. The aim of this study was to investigate the sources of malpractice cases involving pediatric trainees in order to inform the development of strategies to protect against such incidents. Methods LexisNexis, an online public legal research database containing records from the United States, was retrospectively reviewed for malpractice cases involving pediatric interns, residents, or fellows from January 1, 2000 to December 31, 2021. Cases were included if malpractice occurred following delivery of a newborn through the care of young adults up to age 21. Results A total of 56 cases were included consisting of 10 pediatric interns, 43 second or third-year residents, and 11 pediatric fellows as defendants. Seventeen cases (30.4%) led to patient mortality. Incorrect diagnosis or treatment was claimed in 45 cases (80.4%), delay in evaluation in 24 (42.9%), failure to supervise trainee in 22 (39.3%), trainee inexperience in 21 (37.5%), procedural error in 21 (37.5%), lack of informed consent of resident being involved in 2 (3.6%), prolonged operative time in 1 (1.8%), and lack of informed consent of procedure/complications in 1 (1.8%). Conclusions Malpractice cases involving pediatric trainees highlight the importance of adequate supervision by attending physicians. These concerns are not exclusive to interns and residents and necessitate action by all members of the healthcare team. Given the interplay of supervision and diagnostic accuracy, trainee education and faculty development should emphasize malpractice education and strategies to mitigate lawsuits to both improve patient outcomes and reduce likelihood of future malpractice claims.
... It has been well documented that language barriers can lead to poor understanding between medical staff and LEP patients, contributing to increased medical errors [3] and to decreased compliance [4] and medication adherence [5,6]. These negative outcomes in aggregate further contribute to healthcare disparities within LEP patient populations, as summarized extensively in the California Endowment annotated bibliography [7]. ...
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Over 25 million individuals living in America are limited English proficient, many of whom live in rural communities. Adequate language accommodations are critical to providing effective healthcare for these populations. An online questionnaire was delivered to 42 rural facilities in Washington State. It included questions about their demand for language services, modalities of interpretation, translated documentation and barriers to providing accommodations. Fifteen of 42 (35.7%) responded. Spanish, Russian, Vietnamese, Japanese, Ukrainian and Mam were encountered daily. Telephonic and virtual remote interpreter services were the most widely available. Not all facilities had vital documents translated to frequently encountered languages. Challenges to providing language access were reported by nearly all participants. The rural facilities surveyed all encountered LEP patient populations and offered oral interpretation. Overall, these facilities were meeting requirements for providing language accommodation services. Even so, many facilities reported experiencing barriers to providing these services.
... Patients, parents, and their health care teams may experience barriers in communicating through interpreters, particularly if individuals who are not professional medical interpreters are used to facilitate communication [17,[21][22][23]. The situation can be especially challenging if families' preferred language is a language of lesser diffusion with limited availability of professional medical interpreters. ...
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There are significant concerns regarding the increased mortality of patients with asthma. Indeed the paradox of improved pharmacotherapy but worsening prognosis has been explored in depth in several studies including observations in epidemiology, access to medical care, and drug toxicity. Because of our ability to track all admissions to a tertiary-care hospital, we attempted to define the demographic data from a population of asthmatic children admitted for asthma in order to identify risk factors for intubation. We performed a retrospective cohort study of all asthma admissions excluding patients with cystic fibrosis. This study included all asthmatics aged 5-12 years admitted over a 10-year period (1984-1994) to the University of California at Davis Medical Center, Sacramento. A total of 300 such asthma admissions were reviewed, involving 135 girls and 165 boys, mean age 7.7 +/- 2.4 years. Of this group, 166 children were black, 70 were Caucasian, 49 were Hispanic, 14 were Asian, and 1 was an American Indian. By National Heart, Lung, and Blood Institute guidelines, this group included 147 mild, 117 moderate, and 36 severe cases. Thirteen children required intubation for their asthma. Significant risk factors identified for children requiring intubation, compared to those who did not require intubation, were secondhand smoke exposure [odds ratio (O.R.) 22.4; 95% confidence interval (C.I.) 7.4, 68.0], psychosocial problems (O.R. 13.5; 95% C.I. 5.1, 36.0), family dysfunction (O.R. 13.0; 95% C.I. 3.9, 43.9), upper respiratory infection (O.R. 10.2; 95% C.I. 3.4, 28.1), little formal education (O.R. 8.7; 95% C.I. 2.4, 31.6), prior asthma emergency room visit in past year (O.R. 7.2; 95% C.I. 1.9, 27.1), prior asthma hospitalization in past year (O.R. 7.1; 95% C.I. 2.2, 22.2), crowding (O.R. 6.9; 95% C.I. 2.5, 19.1), low socioeconomic status (O.R. 6.5; 95% C.I. 2.1, 20.8), steroid-dependent (O.R. 3.8; 95% C.I. 1.2, 12.1), parental history of allergy or asthma (O.R. 3.4; 95% C.I. 1.1, 10.0), and language barrier (O.R. 3.3; 95% C.I. 1.1, 10.6). Nonsignificant mild risk factors included inhaled cromolyn (O.R. 2.7; 95% C.I. 0.7, 10.0), atopy (O.R. 1.9; 95% C.I. 0.6, 5.9), and prior intubation (O.R. 1.6; 95% C.I. 0.2, 13.1). These risk parameters may be important determinants of baseline risk for asthma deaths and their recognition may have a significant impact on preventive measures.
Article
Objective To isolate the effect of spoken language from financial barriers to care, we examined the relation of language to use of preventive services in a system with universal access. DesignCross-sectional survey. SettingHousehold population of women living in Ontario, Canada, in 1990. ParticipantsSubjects were 22,448 women completing the 1990 Ontario Health Survey, a population-based random sample of households. Measurements and Main ResultsWe defined language as the language spoken in the home and assessed self-reported receipt of breast examination, mammogram and Pap testing. We used logistic regression to calculate odds ratios for each service adjusting for potential sources of confounding: socioeconomic characteristics, contact with the health care system, and measures reflecting culture. Ten percent of the women spoke a non-English language at home (4% French. 6% other). After adjustment, compared with English speakers, French-speaking women were significantly less likely to receive breast exams or mammography, and other language speakers were less likely to receive Pap testing. Conclusions Women whose main spoken language was not English were less likely to receive important preventive services. Improving communication with patients with limited English may enhance participation in screening programs.
Article
OBJECTIVE: To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients. DESIGN: Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records. SETTING: A large HMO in New England. PARTICIPANTS: A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N=327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N=4,053). MEASUREMENTS AND MAIN RESULTS: The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs 0.70; P<.01), prescriptions written (1.76 vs 0.53; P<.01), and prescriptions filled (2.33 vs 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs 0.02; P=.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services. CONCLUSION: Professional interpreter services can increase delivery of health care to limited-English-speaking patients.
Article
OBJECTIVE: To determine whether patients who encountered language barriers during an emergency department visit were less likely to be referred for a follow-up appointment and less likely to complete a recommended appointment. DESIGN: Cohort study. SETTING: Public hospital emergency department. PARTICIPANTS: English- and Spanish-speaking patients (N=714) presenting with nonemergent medical problems. MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to determine sociodemographic information, health status, whether an interpreter was used, and whether an interpreter should have been used. The dependent variables were referral for a follow-up appointment after the emergency department visit and appointment compliance, as determined by chart review and the hospital information system. The proportion of patients who received a follow-up appointment was 83% for those without language barriers, 75% for those who communicated through an interpreter, and 76% for those who said an interpreter should have been used but was not (P=.05). In multivariate analysis, the adjusted odds ratio for not receiving a follow-up appointment was 1.92 (95% confidence interval [CI], 1.11 to 3.33) for patients who had an interpreter and 1.79 (95% CI, 1.00 to 3.23) for patients who said an interpreter should have been used (compared with patients without language barriers). Appointment compliance rates were similar for patients who communicated through an interpreter, those who said an interpreter should have been used but was not, and those without language barriers (60%, 54%, and 64%, respectively; P=.78). CONCLUSIONS: Language barriers may decrease the likelihood that a patient is given a follow-up appointment after an emergency department visit. However, patients who experienced language barriers were equally likely to comply with follow-up appointments.
Article
OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN: Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS: We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS: Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio [OR] 1.17; 95% confidence interval [95% CI] 1.05 to 1.30), failure to explain side effects (OR 1.65; 95% CI, 1.16 to 2.35), and primary language other than English or Spanish (OR 1.40; 95% CI, 1.01 to 1.95). Patient satisfaction was lower among patients who reported drug complications (P < .0001). In addition, 48% of those reporting drug complications sought medical attention and 49% experienced worry or discomfort. On chart review, 3 (5%) of the patients with an adverse drug event required hospitalization and 8 (13%) had a documented previous reaction to the causative drug. CONCLUSIONS: Drug complications in the ambulatory setting were common, although most were not documented in the medical record. These complications increased use of the medical system and correlated with dissatisfaction with care. Our results indicate a need for better communication about potential side effects of medications, especially for patients with multiple medical problems.
Article
Objective: To determine whether physicians at a general internal medicine clinic spend more time with non-English-speaking patients. Design: A time-motion study comparing physician time spent with non-English-speaking patients and time spent with English-speaking patients during 5 months of observation. We also tested physicians' perceptions of their time use with a questionnaire. Setting: Primary care internal medicine clinic at a county hospital. Patients/participants: One hundred sixty-six established clinic patients, of whom 57 were non-English speaking and 109 were English speaking, and 15 attending physicians and 8 third-year resident physicians. Measurements and main results: Outcome measures included total patient time in clinic, wait for first nurse or physician contact, time in contact with the nurse or physician, physician time spent on the visit, and physician perceptions of time use with non-English-speaking patients. After adjustment for demographic and comorbidity variables, non-English-speaking and English-speaking patients did not differ on any time-motion variables, including physician time spent on the visit (26.0 vs 25.8 minutes). A significant number of clinic physicians believed that they spent more time during a visit with non-English-speaking patients (85.7%) and needed more time to address important issues during a visit (90. 4%), (both p <.01). Physicians did not perceive differences in the amount they accomplished during a visit with non-English-speaking patients. Conclusions: There were no differences in the time these physicians spent providing care to non-English-speaking patients and English-speaking patients. An important limitation of this study is that we were unable to measure quality of care provided or patients' satisfaction with their care. Physicians may believe that they are spending more time with non-English-speaking patients because of the challenges of language and cultural barriers.