Language Barriers Increase Risk for Adverse Events and Effects

It has been widely reported that the rising number of foreign-language speakers in the U.S. has created language barriers in hospitals, stretching their resources and putting patients’ safety at risk, but a new study provides further evidence that patients who speak, read, write or understand little or no English--that is, who have Limited English Proficiency (LEP), are at greater risk than English-speaking patients for experiencing adverse events that result in harm during a hospital stay.

“We were not surprised by the results of the study,” said Richard G. Koss, MA, director of the Department of Health Services Research for the Joint Commission and one of the authors of the April 2007 report, Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study, supported by the Commonwealth Fund.

“It confirmed what we had feared, that patients who cannot communicate with their healthcare provider in a common language would suffer patient safety adverse events as a result.”

During a seven-month period in 2005, Koss and his fellow researchers collected and categorized data from 1,083 adverse event incident reports involving English-speaking and LEP patients in six U.S. hospitals. They used the Joint Commission's Patient Safety Event Taxonomy tool to characterize the impact (harm), type and cause of adverse events and near misses.

According to Koss, “The adverse events we found were typical of the everyday patient safety events that continue to occur all too often in healthcare delivery,” such as medication mistakes, patient falls, injuries during treatment, skin breakdowns, equipment problems and other events.

The researchers’ most significant findings were that almost 50 percent of reported adverse events in LEP patients resulted in physical harm compared to about 30 percent in English-speaking patients. Almost twice as many LEP than English-speaking patient adverse events resulted in a more serious level of harm.

Also evaluated were the types of adverse events, such as communication (advice, information, disclosure, consent), patient management (tracking or follow-up of patients) and clinical performance (diagnoses or interventions). LEP patients experienced a greater proportion of adverse events attributable to communication failure (52.4 percent) than did English-speaking patients (35.9 percent). Specifically, questionable advice or interpretation and questionable assessment of patient needs (for such things as pain medication or the presence of allergies) led to a higher percentage of adverse events for LEP patients.

The cause of adverse events, whether due to system factors (organizational factors/management/culture, knowledge transfer, environment, protocols/processes) or human errors (skill, rule, knowledge based) were also reviewed, but not found to be significantly different between the two groups.

In addition to adverse events, other adverse “effects” have been observed in LEP patients. According to Glenn Flores, MD, FAAP, professor of pediatrics and population health at the Medical College of Wisconsin, these can include:

• Impaired health status
• Lower likelihood of having a usual source of medical care
• Lower rates of mammograms, pap smears and other preventive services
• Non-adherence with medications
• Greater likelihood of a diagnosis of more severe psychopathology and leaving the hospital against medical advice among psychiatric patients
• Lower likelihood of being given a follow-up appointment after an emergency department visit
• Increased risk of intubations among children with asthma
• Greater risk of hospital admissions among adults
• Increased risk of drug complications
• Longer medical visits
• Higher resource utilization for diagnostic testing
• Lower patient satisfaction
• Impaired patient understanding of diagnoses, medications and follow-up.

Clearly, there is a growing need for hospitals to develop strategies that break down language barriers and improve the safety and quality of care for their LEP patients.

The Joint Commission’s 2006 standard requiring hospitals to collect and document language information about their patients as part of their accreditation process has forced hospitals to “get serious about tracking who comes through their door and the language needs they have,” said Cynthia E. Roat, MPH, a national consultant on language access in healthcare and founding member, past co-chair of the board and current co-chair of the outreach committee of the National Council on Interpreting in Health Care.

According to Koss and his co-authors, this data helps hospitals to characterize adverse events and understand how language plays a role in patient safety by allowing them to examine their processes, identify areas for improvement and initiate efforts to address any disparities in outcomes for LEP patients.

Although some hospitals may be providing language services to LEP patients, these services might be inadequate, due to unqualified or inaccessible interpreters, for mitigating the patient safety risks posed by language barriers, according to the Joint Commission authors. Ideally, hospitals should provide language services that include a combination of full-time, trained medical interpreters, along with technology (such as telephonic interpreting and video conferencing), with outsourcing the work to external interpretation agencies as an alternative.

However, as previously covered in AMN Healthcare’s online publication, Healthcare Briefings “There is an acute shortage of medical interpreters in the U.S., especially for the less commonly spoken languages,” according to Roat. “This shortage affects everybody, not just LEP patients.”

“The consequence of poor health literacy is a significant problem for the healthcare system and the health of Americans who speak fluent English,” said Koss. “People with LEP are the most vulnerable segment of the population that is health illiterate. By focusing its attention on healthcare disparities research, such as this pilot study, the Joint Commission is actively addressing health literacy and LEP and the impact of language barriers on patient safety.”

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