Do You Rely on "Ad Hoc" Interpreters in Your ED?

Harmed patients have successfully sued

In one case involving the death of a 9-year-old girl from a reaction to metoclopramide, misdiagnosed as gastroenteritis, the patient and her 16-year-old brother were called on in the ED to interpret for their Vietnamese-speaking parents. The ED's written discharge instructions explaining when to return to the ED were signed by the parents, but the instructions were in English.1

"The hospital did not provide competent oral interpreters nor translation of important written documents." says Mara Youdelman, JD, managing attorney in the Washington, DC, office of the National Health Law Program. The case was settled for $200,000.

In another case, a 17-year-old high school girl born in Taiwan who came to the ED reporting a fever and headache after an injury, interpreted for herself until she suffered respiratory arrest. She was transferred to the intensive care unit and taken to surgery, where it was confirmed that she had a brain abscess.1

"She died the following day. The girl's parents alleged that a delayed response by the treating physician led to a delay in the surgery for her brain abscess," says Youdelman.

Lack of an interpreter for a 3-year-old girl presenting to an ED with abdominal pain resulted in several hours delay in diagnosing appendicitis, which later perforated, resulting in peritonitis, a 30-day hospitalization, and two wound site infections.2 In another well-known case, misinterpretation by paramedics and emergency department personnel of a single Spanish word to mean "intoxicated," instead of its intended meaning of "feeling sick to the stomach," led to a $71 million malpractice settlement associated with a potentially preventable case of quadriplegia.3

Errors Very Common

An average of 33 interpreter errors are committed in ED encounters, with as many as 246 errors committed in one encounter, according to a study of two Massachusetts pediatric EDs.4 Glenn Flores, MD, FAAP, professor of pediatrics, clinical sciences, and public health and director of the Division of General Pediatrics at UT Southwestern Medical Center and Children's Medical Center Dallas, and the study's lead author, says he was surprised at the frequency of errors.

"The number of errors in a single encounter is possible because in a longer encounter of an hour or more, an ad hoc interpreter, like a child or family member, could make dozens or even hundreds of errors of interpretation," he explains. About one in five errors had potential clinical consequences, with an average of six errors of potential clinical consequences per encounter, and up to 47 in a single encounter.

"These findings indicate that interpreter errors are common in the ED, and a not inconsequential proportion of these errors have potential clinical consequences," says Flores. This is concerning, he adds, because interpreter errors have been documented to cause or be associated with preventable harm and serious injuries, including overdoses, misdiagnosis, and quadriplegia.

Suits for Failure to Provide

Youdelman says that the biggest liability risk she sees for EPs caring for patients with limited English proficiency is failure to provide competent interpreters. "Too many emergency departments rely on patients, family members, minor children, and other ad hoc interpreters who do not have sufficient command of both English and the non-English language, particularly with regards to medical terminology," she says.

Flores says that while ED patients with limited English proficiency should always be provided with a trained professional interpreter or bilingual health care provider, this doesn't always occur. In a study of 530 Latino adults seen in one urban ED, no interpreter was used for 46% of patients for whom an interpreter was thought necessary by the patient or clinician. When both the clinician's Spanish and the patient's English were poor, interpreters were not called in one-third of the time, and among interpreters used, 39% had no training.5

"Ad hoc interpreters — untrained staff, family members, friends, or strangers pulled from the waiting room or street — should never be used," underscores Flores.

In the study of the two pediatric EDs, professional interpreters resulted in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters.3 Interpreters with at least 100 hours of training committed lower proportions of errors of potential consequence overall and in every error category.

Ka Ming Ngai, MD, MPH, a clinical instructor in the Department of Emergency Medicine at Mount Sinai School of Medicine in New York, NY, says that at a minimum, EPs should document the time and date an interpreting service is used; the name of the interpreter; whether it is an in-person interpreter provided by your hospital, certified ED staff as interpreter, or a phone or video interpreter provided by vendors; and whether the patient refused a professional interpreter offered by the ED. Youdelman says even if a patient refuses a professional interpreter, the ED should involve a professional interpreter to monitor the encounter, ensure accurate communication, and protect the ED from legal risk.

EPs with limited language skills are themselves at risk if they attempt to communicate with patients without using interpreters, cautions Youdelman. "Often, the provider may not have the knowledge of medical terminology in both languages or have insufficient language skills to accurately obtain a patient history, make a diagnosis, discuss treatment options, and obtain patient consent," she adds.

Youdelman adds that EPs face legal risks if they attempt to obtain informed consent from limited English proficient patients without competent interpreters and translated documents. "When a non-English speaking patient merely signs an English document, it is unlikely a court would recognize informed consent," she says.


1. Quan K. The High Costs of Language Barriers in Medical Malpractice. National Health Law Program, 2010.

2. Flores G, Abreu M, Schwartz I, et al. The importance of language and culture in pediatric care: Case studies from the Latino community. J Pediatr. 2000;137:842-848.

3. Harsham P. A misinterpreted word worth $71 million. Med Econ. 1984;61:289-292.

4. Flores G, Abreu M, Barone CP, et al. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012 Mar 14. [Epub ahead of print].

5. Baker DW, Parker RM, Williams MV, et al. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275:783-788.


For more information, contact:

• Glenn Flores, MD, FAAP, Professor and Director, Division of General Pediatrics, UT Southwestern and Children's Medical Center Dallas. Phone: (214) 648-3405. E-mail:

• Ka Ming Ngai, MD, MPH, Clinical Instructor, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY. Phone: (212) 824-8074. E-mail:

• Mara Youdelman, Managing Attorney, National Health Law Program, Washington, DC. Phone: (202) 289-7661. E-mail: