Background. About 19 million people in the United States are limited in English proficiency, but little is known about the frequency and potential clinical consequences of errors in medical interpretation.
Objectives. To determine the frequency, categories, and potential clinical consequences of errors in medical interpretation.
Methods. During a 7-month period, we audiotaped and transcribed pediatric encounters in a hospital outpatient clinic in which a Spanish interpreter was used. For each transcript, we categorized each error in medical interpretation and determined whether errors had a potential clinical consequence.
Results. Thirteen encounters yielded 474 pages of transcripts. Professional hospital interpreters were present for 6 encounters; ad hoc interpreters included nurses, social workers, and an 11-year-old sibling. Three hundred ninety-six interpreter errors were noted, with a mean of 31 per encounter. The most common error type was omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). Sixty-three percent of all errors had potential clinical consequences, with a mean of 19 per encounter. Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters (77% vs 53%). Errors of clinical consequence included: 1) omitting questions about drug allergies; 2) omitting instructions on the dose, frequency, and duration of antibiotics and rehydration fluids; 3) adding that hydrocortisone cream must be applied to the entire body, instead of only to facial rash; 4) instructing a mother not to answer personal questions; 5) omitting that a child was already swabbed for a stool culture; and 6) instructing a mother to put amoxicillin in both ears for treatment of otitis media.
Conclusions. Errors in medical interpretation are common, averaging 31 per clinical encounter, and omissions are the most frequent type. Most errors have potential clinical consequences, and those committed by ad hoc interpreters are significantly more likely to have potential clinical consequences than those committed by hospital interpreters. Because errors by ad hoc interpreters are more likely to have potential clinical consequences, third-party reimbursement for trained interpreter services should be considered for patients with limited English proficiency.
Comments
First Person Interpretation Techniques
My wife is a medical interpreter and I'm an electrical engineer. I have worked on a number of overseas industrial projects where communication was through an interpreter.
We present a 1 hour talk, "Working Through an Interpreter", to groups of nurses participating in a continuing education program at SHMC, a hospital in Spokane Washington. We advocate the use of "first person" techniques which are very effective and I believe could eliminate many of the errors identified in this study.
Using first person techniques, the provider and patient make eye contact and talk directly to each other, pausing after each phrase or sentence, allowing the interpreter to repeat the phrase or sentence in the other language. When done in this way the interpreter does not have a chance to editorialize, make omissions, or to otherwise control the conversation. In addition the provider and patient are able to non- verbally communicate directly with each other.
Anecdotal examples given in the article seem to use a third person technique (i.e. "Tell her that ...", "What did he say..", etc). I am curious if any of the interpretation sessions were conducted using the "first person" technique and if so, did it have any effect on the error rate or potential clinical consequences.
I think it would be interesting to take into account the interpretation techniques used (i.e. fist-person vs third-person) in a future study of this type.
I offer the above comments in the hope that someone will find them interesting or useful. ;)
Conflict of Interest:
Spouse works as a medical interpreter.
Ad Hoc Translators Not That Bad!
When I read this article closely, I come to a different conclusion than the authors seem to.
Of the 13 interpreted visits studied, 6 were with "qualified" and 7 were with "ad-hoc" interpreters. "Qualified" interpreters averaged 39 errors / visit (14-60, "ad hoc" interpreters 24 (10-58), with no statistical difference between the two.
Of "errors of potential medical significance", "qualified" interpreters ageraged 20 / visit (5-34), "ad hoc" interpreters 18 / visit (8-49), with the difference probably not significant statistically or clinically.
Statistical significance in group differences in percent all errors that were medically significant, but this statistic is likely flawed by an inflated denominator, i.e., the fact that when a "qualified interpreter" was used, the clinicians made a lot more "fluency errors". And, in this analysis, I see little or no clinical significance.
Both groups made too many errors. Clinicians must be on guard for interpretation erros with both types to minimize the adverse medical care consequences.