How To Improve Safety For Patients With Limited English Proficiency

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Our Nation is becoming increasingly diverse and the role of language barriers and their impact on adverse events is now receiving greater attention. Approximately 25 million, or 8.6 percent of the U.S. population, are defined as limited English proficient (LEP), meaning that they speak English less than "very well." This number is expected to grow, as projections indicate the U.S. will continue to become more diverse. Recent research suggests that this growing segment of the U.S. population is at risk for adverse events because of barriers associated with limited English proficiency.

Common Causes of adverse events for LEP and culturally diverse patients include:

1.  Use of Family Members/Friends or Nonqualified Staff as Interpreters

  • Family members and friends typically may not understand the subtle nuances of language and culture that may influence the interaction and may not question the use of medical terminology that they and the patient do not understand. Further, issues of confidentiality may prevent patients from disclosing critical health information.
  • Research confirms that untrained hospital staff often serve as interpreters for LEP patients, despite evidence that hospital staff who serve as interpreters on an ad hoc basis are more likely to make clinically significant mistakes than qualified medical interpreters.

2.  Use of Basic Language Skills To "Get By"

  • Clinicians with basic or intermediate foreign language skills often attempt to "make do" or "get by" without the use of a competent interpreter, increasing patient risk.

3.  Cultural Beliefs and Traditions Affecting Patient Care

  • Cultural beliefs and traditions, such as minimizing reports of pain, deferring to authority figures, and following certain gender roles, can influence the medical encounter and compound the risk for LEP patients.

What are the steps and strategies to help improve safety for LEP patients?  Hospitals can engage in a systematic approach to better identify and prevent medical errors and adverse events that commonly occur among LEP patients.  Here are 5 ways to help improve safety for LEP patients:

1.  Foster a supportive culture for safety of diverse patient populations, articulated clearly by leadership, operationalized in strategic planning for the organization, and supported by providing staff with key tools and resources to accomplish this successfully.

  • Link the goal of overcoming language and cultural barriers into the overall message and mission of the culture of quality and safety, and frame this within existing operational policies and standards related to quality and safety for all patients.
  • Share lessons learned from patient safety events with all staff to help build an institutional culture sensitive to issues that affect LEP patients and ensure ongoing continuous learning and training in this area.
  • Involve patients in family advisory councils or cultural advisory groups to incorporate patient perspectives.

2.  Adapt current systems to better identify medical errors in LEP patients, improve the capacity of patient safety systems to capture key root causes and risk factors, and link databases so that information is readily accessible.

  • Document data in the electronic medical record on race, ethnicity, and patient language and interpreter service needs to allow ongoing monitoring and easy integration with other reporting systems for quality of care monitoring purposes.
  • Include these data fields in patient safety systems to track the role of language and culture in the patient safety events reported by staff.

3.  Empower frontline staff and interpreters to report medical errors, and provide them with training and systems to do so effectively and efficiently.

  • Develop targeted messages so that frontline staff and interpreters are empowered to report any patient safety events they might encounter.
  • Train all staff, particularly frontline staff and interpreters, on the full spectrum of what constitutes a patient safety event (including near misses) and how to report them.
  • Consider other methods of identifying errors outside of standard reporting.

4.  Monitor patient safety among LEP patients, as well as developing processes to analyze medical errors and near misses that occur among these populations.

  • Develop routine (quarterly, yearly) hospitalwide safety reports or dashboards that focus on patient safety among LEP patients.
  • Create routine forums for analyzing cases of medical errors and near misses that occur among LEP and culturally diverse populations to better understand root causes and high-risk scenarios, and develop strategies for improvement and error prevention.

5.  Prevent medical errors among LEP patients by strengthening interpreter services. Improve coordination with the provision of clinical services, provide translated materials, and develop training for health care providers and staff on interpreter use, cultural competency, and advocacy. Immediate strategies that can be implemented are improving access to interpreters presents an overview of benefits and challenges of interpreters providing cultural brokerage) and offering TeamSTEPPS® training.

  • Develop dedicated services for medical interpretation that include either in-person or telephonic qualified medical interpreters, or both.
  • Provide patients with written materials – such as for informed consent or procedure preparation – in their preferred written language.
  • Create a mechanism to schedule an interpreter automatically at clinical points of service for patients who are identified as having LEP.
  • Train staff on team communication, use of interpreter services, cultural competency, and advocacy.

For additional information and to learn more about the TeamSTEPPS LEP Module, visit http://www.ahrq.gov/professionals/systems/hospital/lepguide/index.html.

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