DiversityNursing Blog

From The Associated Press via SouthCoastToday.com

A visit to the emergency department or a physician's office can be confusing and even frightening when you're trying to digest complicated medical information, perhaps while you're feeling pain or discomfort. For the 25 million people in the United States with limited English proficiency, the potential for medical mishaps is multiplied.

A trained medical interpreter can make all the difference. Too often, however, interpreter services at hospitals and other medical settings are inadequate. Family members, including children, often step in, or the task falls to medical staff who speak the required language with varying degrees of fluency.

According to a study published in March, such ad hoc interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters.

The study, published online in the Annals of Emergency Medicine, examined 57 interactions at two large pediatric emergency departments in Massachusetts. These encounters involved patients who spoke Spanish at home and had limited proficiency in English.

Researchers analyzed audiotapes of the visits, looking for five types of errors, including word omissions, additions and substitutions as well as editorial comments and instances of false fluency (making up a term, such as calling an ear an "ear-o" instead of an "oreja").

They recorded 1,884 errors, of which 18 percent had potential clinical consequences.

For professionally trained interpreters with at least 100 hours of training, the proportion of errors with potential clinical significance was 2 percent. For professional interpreters with less training, the figure was 12 percent. Ad hoc interpreter errors were potentially clinically significant in nearly twice as many instances — 22 percent. The figure was actually slightly lower — 20 percent — for people with no interpreter at all.

It makes sense that trained interpreters, especially those with more experience, would make fewer errors, says Glenn Flores, a professor and director of the division of general pediatrics at UT Southwestern Medical Center and Children's Medical Center of Dallas, who was the study's lead author. Experienced interpreters "know the medical terminology, ethics, and have experience in key situations where you need a knowledge base to draw on," he says.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color or national origin. Courts have interpreted that to mean that all health-care providers that accept federal funds — because they serve Medicare and Medicaid recipients, for example — must take steps to ensure that their services are accessible to people who don't speak English well, according to the National Health Law Program, a nonprofit that advocates for low-income and underserved people. (Doctors whose only federal payments are through Medicare Part B are exempt from this requirement, however.) The Census Bureau estimates that nearly 9 percent of the population age 5 or older has limited English proficiency, which the bureau defines as people who describe themselves as speaking English less than "very well."

Hospitals and other medical providers are in a tough spot, say experts. The law prohibits them from asking patients to pay for translation services, and they may not receive adequate or in some cases any other reimbursement. "It's a civil rights law, not a funding law," says Mara Youdelman, managing attorney in the Washington office of the National Health Law Program.

A dozen states and the District of Columbia reimburse hospitals, doctors and other providers for giving language services to enrollees in Medicaid, the joint federal-state program for low income people, and in CHIP, a federal-state health program for children, according to Youdelman. Virginia and Maryland do not.

A 2008 survey by America's Health Insurance Plans, an industry trade group, found that 98 percent of health insurers provide access to interpreter services, but providers and policy experts question that figure. According to a survey by the Health Research and Educational Trust, in partnership with the American Hospital Association, 3 percent of hospitals received direct reimbursement for interpreter services, most of that from the Medicaid program.

"Most hospitals that make this a priority make it a budget item," Youdelman says.

Hospitals and other providers realize that offering competent interpreter services can help ensure that they don't miss or misdiagnose a condition that results in serious injury or death, experts say. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures.

Youdelman cites the example of a Russian-speaking patient in Upstate New York who arrived at an emergency department saying a word that sounded like "angina." The emergency staff ran thousands of dollars' worth of tests, thinking he might be having a heart attack. The real reason for his visit: a bad sore throat.

Like many hospitals, Children's Medical Center of Dallas provides interpreter services around the clock via varying modes of communication — face-to-face, telephone and video — delivered by a mix of trained staff interpreters and outside contractors.

When Nadia Compean, 23, was six months pregnant, her doctor in Odessa, Texas, told her that her baby had spina bifida, a condition in which the spinal cord doesn't close properly, leading to permanent nerve and other damage.

The local hospital wasn't equipped to handle the birth and subsequent surgery that her daughter would require, so Nadia and the child's father traveled to Dallas, about 350 miles away.

Neither speaks much English, but at Children's Medical Center of Dallas, interpreters helped them understand what to expect, Nadia said (through an interpreter).

Nadia says she learned that her daughter, Eva, would be born with a lump on her back and would require immediate surgery. She also learned about problems that Eva may experience walking and using the toilet, she says.

Eva was born March 6. Because of her medical needs and the lack of adequate interpreter services in Odessa, the couple is considering relocating to Dallas, where the father hopes he can find construction work.

This column is produced through a collaboration between The Washington Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.

Having professional translators in the emergency room for non-English-speaking patients might help limit potentially dangerous miscommunication, a new study suggests.

But it hadn't been clear how well professional interpreters perform against amateurs, such as an English-speaking family member, or against no translator at all.

The current findings, reported in the Annals of Emergency Medicine, are based on 57 families seen in either of two Massachusetts pediatric ERs. All were primarily Spanish-speaking.
The research team audiotaped the families' interactions with their ER doctor. Twenty families had help from a professional interpreter and 27 had a non-professional. Ten had no translation help.

It's not clear why some families had no professional interpreter. In some cases, Flores said, there may have been no one available immediately. Or the doctor might not have requested an interpreter.

The findings suggest that professionals can help avoid potentially dangerous miscommunication between patients and doctors, according to Flores and his colleagues.
In one example from their study, an amateur interpreter -- a family friend -- told the doctor that the child was not on any medications and had no drug allergies. But the friend had not actually asked the mother whether that was true.

Cost questions

There are still plenty of questions regarding professional interpreters, according to Flores.
For one, he said studies are needed to compare the effectiveness of in-person professional translators versus phone and video translation services.

There are also questions about what type of translation help families and doctors prefer, and what's most cost-effective. Federal law may require many hospitals to offer interpreters, but it does not compel the government or private insurance to pay for them. Right now, some U.S. states require reimbursement, but the majority do not. So in most states, Flores told Reuters Health, "the hospitals and clinics, and ultimately the taxpayers (because of uncompensated/charity care), are left covering the costs." But the cost-per-patient can be kept down. One study found that when a group of California hospitals banded together to offer translators by phone and video, the cost per patient was $25.

As for national costs, Flores pointed to a 2002 report from the White House Office of Management and Budget. It estimated that it would cost the U.S. $268 million per year to offer interpreter services at hospitals and outpatient doctor and dentist visits.

Another issue is training -- including the question of how much is enough. In the current study, errors were least common when interpreters had 100 hours of training or more: two percent of their translation slips had the potential for doing kids harm. There are numerous training programs for medical interpreters nationwide. But few of them provide at least 100 hours of training, Flores noted.

As for hospitals, it seems that most do not offer their own training programs. And even when they do, the hours vary substantially, Flores said. Based on these findings, he and his colleagues write, requiring 100-plus hours of training "might have a major impact" on preventing translation errors -- and any consequences for patients' health.

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Have you ever used a translator as a nurse or as a patient? How did it go? What is the ideal training program?

Mr. W had a heart attack and was in the ICU last week.  While reviewing his discharge medication list, you realize Mr. W unintentionally discontinued his medication for hypertension and dyslipidemia.  Unfortunately, these medications were not on the discharge medication list.  

Jay has been a well controlled diabetic for many years.  Today his A1C is 10.5.  He insists he is taking his medication regularly.  

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. ¹   Efforts to decrease or prevent medication errors often focus on improving systems and procedures utilized by nurses, physicians and pharmacists during the multistep process of medication administration.  Decreasing medication errors by patients must also be addressed.  

According to the landmark 2006 report "Preventing Medication Errors" from the Institute of Medicine, medication errors injure 1.5 million Americans each year and cost 3.5 billion in lost productivity, wages and additional medical expenses.^​2 1/3 of medication errors occur in outpatient settings.  Patients often unintentionally discontinue medications after a hospitalization or transfer of care.  Numerous studies have shown that patients with chronic conditions adhere only to 50% to 60% of medications as prescribed despite evidence that medical therapy prevents death and improves quality of life.³   Knowledge deficits and poor understanding of drug label directions often result in medication errors initiated by patients. 

How to reduce medication errors by patients:

1. Decrease medication knowledge deficits.  Review with patients in plain language what medications were prescribed, how to take them, discuss side effects and address concerns regarding drug interactions and cost.  Use visuals and show me techniques to ensure patient understanding.  Enlist the help of the PCP and pharmacist for additional education.
2. 2.   An accurate medication list that includes discharge medications and/or chronic care medications is essential.  Learn how to take an accurate medication history.    Use clear communication techniques during conversations with patients.  Provide patient and PCP with discharge medication list.   
3. Monitor for medication adherence.  Ask patients to bring in all of their medications or contact pharmacies for information on most recent refill dates.  Evaluate and address medication knowledge deficits.  Medication reminders, automatic med refills, medication home delivery, assistance of family members or home care services can be utilized to improve adherence.  Call recently discharged patients to ensure they are taking prescribed medications and chronic care medications. 

Stephanie Wilborne, APRN

HealthLit.com:  Clear & Simple Patient Education/ Tools for Chronic Disease Management

¹ National Coordinating Council for Medication Error Reporting and Prevention: http://www.nccmerp.org/aboutMedErrors.html

²Anderson, Pamela, and Terri Townsend. "Medication errors: Don't let them happen to you." American Nurse Today 5.3 (2010): 23-27: http://www.nursingworld.org/mods/mod494/MedErrors.pdf

³ Bosworth, Hayden, Bradi Granger, Stephen Kimmel, Larry Liu, John Musaus, William Shrank, Elizabeth Buono, Karen Weiss, Christopher Granger, Phill Mendys, Ralph Brindis, Rebecca Burkholder, Susan Czajkowski, Jodi Daniel, Inger Ekman, Michael Ho, and Mimi Johnson. "Medication adherence: A call for action." American Heart Journal 162.3 (2011): 412-424. Print.

⁴ Preventing Medication Errors: Quality Chasm Series Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors