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Quick Safety - Issue Thirteen, May 2015

May 28, 2015
 

Overcoming the challenges of providing care to LEP patients

Issue:

If your organization hasn’t experienced the challenges of providing care to a patient with limited English proficiency (LEP), the likelihood of it happening in the near future is very good. Approximately 57 million people, or 20 percent of the U.S. population, speak a language other than English at home, and approximately 25 million, or 8.6 percent of the U.S. population, are defined as being LEP.1 There is a large and growing population of LEP patients. According to Pew Research Center, between 2000 and 2013, non-Hispanic whites became the minority population in 97 counties in the U.S.2 It is also projected that by 2021, approximately 50 percent of the newly insured will be minorities, and less likely to speak English.3 See the sidebar for more statistics.

LEP patients are at a higher risk for adverse events than English-speaking patients. Language barriers significantly impact safe and effective health care. A study analyzed 1,083 adverse-incident reports from six Joint Commission-accredited hospitals for LEP and English-speaking patients for seven months in 2005. The study found that 49.1 percent of LEP patients experienced physical harm versus 29.5 percent of English-speaking patients. The LEP patients also experienced higher levels of physical harm ranging from moderate temporary harm (46.8 percent) to death (24.4 percent).4

When compared to English-speaking patients, LEP patients have:5

  • Longer hospital stays when professional interpreters were not used at admissions and/or discharge

  • Greater risk of line infections, surgical infections, falls, and pressure ulcers

  • Greater risk of surgical delays due to difficulty understanding instructions, including how to prepare for a procedure

  • Greater chance of readmissions for certain chronic conditions due to difficulty understanding how to manage their conditions and take their medications, as well as which symptoms should prompt a return to care or when to follow up

The following scenario was adapted from an online video produced by the U.S. Department of Justice Civil Rights Division. It illustrates the inherent difficulties and dangers of trying to provide care to an LEP patient without the use of appropriate and effective interpretive services or tools.6 

Scenario: A non-English speaking Asian male walks into the emergency room (ER) triage area holding his right wrist. He tells the triage coordinator (TC) he fell and his wrist hurts a lot. He is asked if he speaks English and he says “no.” The TC calls a nurse and tells him there is a patient who doesn’t speak English. The nurse calls a hospital computer tech who is Asian, tells her there is a patient in the ER who doesn’t speak English, and her help is needed to interpret. The computer tech says she speaks Thai, but she might be able to help. The patient is put on the phone, and he tells the tech his pain is getting worse. She does not understand, but thinks the language is Vietnamese. The nurse remembers there is a Vietnamese clerk but finds out she has gone home. The nurse takes the patient into the ER, where he tries to tell the physician his pain is worse. The physician attempts to obtain a history, but is not able to understand. The physician orders an X-ray and a pain medicine for the patient. After taking the medicine, the patient is left unattended and is later found on the floor, unresponsive, and a code is called.6

The following are actual patient-safety reports from one hospital in a study7 of LEP patients:

  • A new patient arrived in the infusion unit for the first IP taxol appointment without orders, consent, or a recent physician’s note. The patient did not speak English. An interpreter and MD were called. This resulted in a delay in treatment.

  • Informed consent was obtained, with no Spanish interpreter, in the ER. The patient did not understand the procedure when asked by the interpreter.

  • The patient is Ethiopian speaking. On multiple occasions, there had been a failure to provide an interpreter. She has been using family members to translate, and they are not always available. This is unacceptable, as we have had issues with medications (i.e., which to take, when), and I believe her worsening diabetes is a direct result of my inability to have effective clinical meetings with her.

Typical failures related to LEP patients that may occur in your organization include:

  • Use of family members, friends, or nonqualified staff as interpreters

  • Provider use of basic language skills to “get by”

  • Cultural beliefs and traditions that affect care delivery, such as expression of pain, respecting authority, gender roles, and class biases

Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands. Effective communication allows patients to participate more fully in their care. When a patient understands what is being said about his or her care, treatment, and services, that patient is more likely to fulfill critical health care responsibilities. Communicating effectively with patients is also critical to the informed consent process, helping practitioners and health care organizations give the best possible care. For communication to be effective, the information provided must be complete, accurate, timely, unambiguous, and understood by the patient. Many patients of varying circumstances require alternative communication methods, including:

  • Patients who speak and/or read languages other than English

  • Patients who have limited literacy in any language

  • Patients who have visual or hearing impairments

  • Patients on ventilators

  • Patients with cognitive impairments

  • Children

Health care organizations have many options available to assist in communication with these individuals, such as interpreters, translated written materials, pen and paper, communication boards, and speech therapy. It is up to the organization to determine which method is the best for each patient.

There are laws, regulations, and a body of literature that are relevant to the use of interpreters. These include Title VI of the Civil Rights Act, 1964; Executive Order 13166; policy guidance from the Office of Civil Rights regarding compliance with Title VI, 2004; Title III of the Americans with Disabilities Act, 1990; state laws (many states have laws and regulations that require the provision of language assistance); and the American Medical Association Office Guide to Limited English Proficiency (LEP) Patient Care.

The safety risks associated with LEP patient care also extend to organizational risk. There are several areas of risk management that require quality planning, which include:

  • Patient comprehension of medical condition

  • Treatment plan

  • Transitions of care

  • Complications and continuity of care

  • Accuracy of the medical record

  • Medication reconciliation

  • Informed consent

  • Preparation for tests and procedures

Safety Actions to Consider:

It is critical to patient safety that organizations maintain collective mindfulness, particularly when there are high-risk and complex situations involving LEP patients. Some of these situations are medication reconciliation, transitions of care, informed consent, urgent and emergency care, and surgical care. Communication needs of LEP patients must be addressed across the care continuum.

The Agency for Healthcare Research and Quality (AHRQ) offers some systems and strategies1 to facilitate communication among hospitals and LEP patients, including:

  • Foster a supportive culture for safety of diverse patient populations

  • Adapt current systems to better identify medical errors among patients with LEP

  • Improve reporting of medical errors (including sentinel events and near misses)

  • Routinely monitor patient safety in LEP patients

  • Address root causes to prevent medical errors among LEP patients

In addition, encourage staff to follow best practices8 during an encounter with a LEP patient and an interpreter.

Resources:

1. Agency for Healthcare Research and Quality: Improving patient safety systems for patients with limited English proficiency: A guide for hospitals (accessed May 11, 2015)
2. Krogstad JM: Reflecting a racial shift, 78 counties turned majority-minority since 2000. Pew Research Center, April 8, 2015 (accessed May 11, 2015)
3. Hunt S, Isgur B: The race to 2014: Health reform and the 30 million newly insured. PwC Health Research Institute, February 6, 2013 (PowerPoint – accessed May 11, 2015)
4. Divi C, Koss RG, Schmaltz SP, Loeb JM: Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study. International Journal for Quality in Health Care, 2007;19:60–7
5. Betancourt JR, Tan-McGrory: “Creating a safe, high-quality healthcare system for all: Meeting the needs of limited English proficient populations; Comment on ‘Patient safety and healthcare quality: The case for language access.’” International Journal of Health Policy and Management 2014;2(2):91-94 (accessed May 11, 2015)
6. U.S. Department of Justice, Civil Rights Division, Language Access: Breaking down the language barrier: Translating limited English proficiency into practice (video – accessed May 11, 2015)
7. Wasserman M, et al: Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. Journal for Healthcare Quality  2014 May-June;36(3):5-16 (abstract accessed May 12, 2015)
8. Reunanen C: Working with interpreters to enhance the provider-patient relationship (Part 1). Sourced from materials created by the Washington Department of Health, and used with permission. Physicians Insurance, Taking Care, December 11, 2013 (accessed May 11, 2015)

Resources from The Joint Commission
The Advancing Effective Communication Web page provides a number of resources:

Note: This is not an all-inclusive list.

 

 

 

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