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Speak my language: Lax interpreting may be a root cause of medical errors
Dangerous to rely on family, ad hoc translators to relay medical information
Translating medical information for patients who don’t speak English has always been a difficult issue for health care providers, but evidence is mounting to suggest that health care providers risk major lawsuits from medical errors traced to inadequate translation. Translators commonly make important errors, according to new research, and most providers need to formalize their translation services instead of relying on whoever you can find to speak the language.
If risk managers had any doubt about the risk posed by translators, new research from the Medical College of Wisconsin in Milwaukee makes the danger crystal clear. Glenn Flores, MD, director of community outcomes in the department of pediatrics and an associate professor of pediatrics, epidemiology, and health policy, recently studied the accuracy of translators in health care situations and found that errors were common and significant.1
"Interpreter errors could be a previously unrecognized root cause of medical errors," Flores tells Healthcare Risk Management.
The resulting medical errors could lead directly to lawsuits, says Grena Porto, RN, ARM, DFASHRM, senior director of clinical operations at VHA Inc. in Berwyn, PA, and past president of the American Society for Healthcare Risk Management. A plaintiff recently was awarded $71 million when paramedics misinterpreted the word "intoxicado" to mean that the unconscious man was drunk.2 They reported that the patient was intoxicated and he was treated accordingly. In actuality, his girlfriend was trying to tell them that he had been nauseated before collapsing, Flores says. The patient’s true condition was not diagnosed for two days, and he was left a quadriplegic.
Two New York hospitals were sued in 2002 for failing to provide translation services to non-English-speaking patients. Advocates for the Hispanic community filed suit against Wyckoff Heights Hospital and Woodhull Hospital, both located in Bushwick, a heavily Hispanic section of northern Brooklyn. A Woodhull Hospital spokeswoman tells HRM that the suit has not been settled yet. The hospital has a volunteer translation pool of 625 staff members who collectively speak 50 languages.
In addition to the risk of lawsuits from medical errors, the 1964 Civil Rights Act requires that language barriers not prevent patients from receiving adequate medical care. The Department of Health and Human Services has indicated in past years that it would stiffen requirements for translation services, but the Bush administration more recently softened its stance. That doesn’t lessen the liability risk or the risk to patients, Porto says.
"We’ve known this is a problem for years," she says. "Too many health care providers have gotten by with translation services that aren’t as sophisticated as they need to be, taking the convenient way just to get by. It’s time for us to start tightening up and making this more of a formal, organized approach."
Family members not good translators
In other words, Porto says, the days are long gone when you could depend on a family member to translate or informally pull in a staff member from housekeeping who happens to speak the language. Those methods always were fraught with danger, she says, but few risk managers were motivated to institute a more formal system. Now that the connection to patient safety and lawsuits is so clear, Porto says you must evaluate your translation services.
Flores agrees, saying his research removes any doubt about how dangerous translation errors can be. His recent study shows an average of 31 medical interpretation errors per patient visit. Mistakes by ad hoc interpreters — family members or staff not specifically designated as translators — were more likely to have potential clinical consequences than those made by professional hospital interpreters — 77% vs. 53%. Errors are more likely in an emergency. The results come from tape-recorded encounters between pediatricians and Spanish-speaking mothers in a Boston hospital outpatient clinic. The ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. The errors fell into these categories:
Examples included an interpreter telling a mother to put oral amoxicillin in the child’s ear to treat infection. Another interpreter told the mother to start using a topical steroid on the baby in four days, when the doctor actually said to start it immediately and use it for four days. Sixty-three percent of the errors were found to have potential medical consequences. Designated interpreters and ad hoc interpreters made errors at about the same rate, Flores says, but the ad hoc interpreters were much more likely to make errors that could jeopardize patient safety.
"When you rely on people like family members, we see that the family member sometimes isn’t as honest or as capable as you think," Porto says. "You’re asking them to translate complicated things about CAT scans and surgery, things that may even be beyond the abilities of someone who speaks English. And then if you’re asking a child to translate for his parents, it gets worse."
Translation always carries a risk of distorting the original message, Porto says, so it is important to minimize that possibility by using trained translators. And she points out that family members are not always completely honest in translating, particularly with sensitive matters such as family violence, sexual assault, drug abuse, and terminal illnesses. The doctor may never know what information the patient actually received or what the patient actually was trying to tell the doctor.
"Our duty as health care providers is to make the patient understand, not just to utter the words," Porto says. "Often I hear people say, Well, I told them.’ But if you didn’t tell them in a way they understand, you didn’t really tell them. You didn’t fulfill your duty."
A good option — if you can afford it
Flores and Porto agree that the research indicates a need to improve translation services. Flores says health care providers should employ and train professional interpreters, while Porto says that is not necessarily the only way to improve translation services. Fewer than a quarter of hospitals nationwide employ professional translators, Flores says.
"One of the most important messages from our work is that you need to avoid using ad hoc interpreters — friends, people pulled from the waiting room, maintenance workers," Flores says. "They don’t have any formal training, don’t know medical terminology, and they can’t provide confidentiality."
But also be cautious of health care providers who speak the second language. They may not be any better as translators, Porto says. Without properly screening health care workers to gauge their abilities and emphasize the proper technique of translation, you can’t be sure whether a physician, nurse, or X-ray technician is translating properly. "False fluency" often trips up well-meaning health care workers, Flores says. They think they can speak German because they studied it for two semesters in college. Then they either mistranslate and never know they made a mistake or they realize they are in over their heads but do their best with the words they know.
Only 14% of hospitals provide training for volunteer interpreters, and training is not mandatory in half, Flores says. Only 23% provide training for clinicians on how to work with interpreters, and in many of those hospitals, the training only amounts to how to request a translator.
Flores acknowledges that most health care providers cannot afford to hire a permanent staff of translators specially trained for medical situations, but he says that is the ideal solution if you have the resources. Some states — Hawaii, Maine, Minnesota, Utah, and Washington — have eased the burden by providing reimbursement for medical translation services.
Providing proper translation services actually can reduce some other costs for the health care provider, he says. When the doctor is not confident about communicating with the patient or family, he or she is much more likely to practice defensive medicine and order more tests.
"The physician has to be safe, so if an adult is admitted with chest pain and there’s no interpreter, the patient is much more likely to be admitted," Flores says. "You spend a lot more in resources when you have a language barrier."
Most providers cannot afford a full-time translation staff, Porto says, and for some locations, that would not be justified even if they could afford it. Another solution is to certify staff members as designated translators and obtain trustworthy outside translation, she says.
Some health care providers make a stab at that solution by sending out a survey among staff asking for volunteers who can speak another language, but Porto cautions that simply asking is not enough. People can be overconfident of their skills. Such a survey might be a good first step in looking for translators, but then you should organize those people and conduct testing to determine their fluency. Language programs at local universities may be able to assist with testing. Even those who are fluent in the language probably will need further education in medical terminology.
How much you need to formalize your translation services will depend a great deal on your local community, Porto says. If your health care facility is in an urban area with lots of different ethnic groups, you may need to put a lot more effort and resources into improving your program. If you are in a rural community with little exposure to language difficulties, the risk of problems is much less. But even in that situation, Porto says you must have a contingency plan for the day an Armenian immigrant shows up in your emergency department. One option is subscribing to a commercial service offering telephone or computer links to professional translators 24 hours a day.
The costs are unavoidable, Porto and Flores say. If you want to improve your translation services, it is practically impossible to do it without spending money. How much depends on your own situation and resources. But they say the cost is justified.
"Given that so many people in our country speak another language, you can either pay a little up front or you can pay a lot after you have medical errors," Flores says.
1. Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 2003; 111:6-14.
2. Harsham P. A misinterpreted word worth $71 million. Med Econ 1984; 61:289-292.