Transcript the Slides Only - American Academy of Pediatrics

Racial/Ethnic Disparities
and Patient Safety
Thursday, November 15, 2007
12:00 – 1:00 p.m. ET
Moderator:
Erin R. Stucky, MD, FAAP
Pediatric Hospitalist
Children’s Specialists of San Diego
Rady Children’s Hospital
San Diego, California
This activity was funded through an
educational grant from the Physicians’
Foundation for Health Systems
Excellence.
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DISCLOSURES
Safer Health Care for Kids - Webinar
Racial/Ethnic Disparities and Patient Safety
November 15, 2007
Activity Title:
Activity Date:
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP
CME activities are required to disclose to the AAP and subsequently to
learners that the individual either has no relevant financial relationships or
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product(s) and/or provider of commercial services discussed in CME
activities.
Name
Glenn Flores, MD,
FAAP
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producing
health care
goods
or services)
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(If yes, please list:
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excluding mutual
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Reference to
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(Unapproved)/Investigational Uses of Products
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and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices
that are not approved
No
No
No
No
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disclose to the AAP and subsequently to learners that the individual either has no relevant financial
relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or
provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
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Financial Relationship(s)
(If yes, please list:
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excluding mutual funds,
Consultant, Other - identify)
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of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Karen Frush, MD, FAAP
(PAC Member)
No
No
No
No
Uma Kotagal, MD, MBBS,
MSc, FAAP (PAC Member)
No
No
No
No
Christopher Landrigan, MD,
MPH, FAAP (PAC Member)
No
No
No
Not sure
Marlene R. Miller, MD, MSc,
FAAP (PAC Chair)
No
No
No
No
Paul Sharek, MD, MPH.
FAAP (PAC Member)
No
No
No
No
Erin Stucky, MD, FAAP (PAC
Member)
No
No
No
No
Nancy Nelson (AAP Staff)
No
No
No
No
Melissa Singleton, MEd
(Project Manager – AAP
Consultant)
No
No
No
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Junelle Speller (AAP Staff)
No
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No
No
Rev 9/2007
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DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Ellen Buerk, MD, FAAP
No
No
No
No
Meg Fisher, MD, FAAP
No
No
No
No
Robert A. Wiebe, MD, FAAP
No
No
Not sure
No
Jack Dolcourt, MD, FAAP
No
No
No
No
Thomas W. Pendergrass, MD,
FAAP
No
No
No
No
Beverly P. Wood, MD, FAAP
No
No
No
No
CME CREDIT
The American Academy of Pediatrics (AAP) is
accredited by the Accreditation Council for
Continuing Medical Education to provide continuing
medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™.
Physicians should only claim credit commensurate
with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credit.
This credit can be applied toward the AAP CME/CPD
Award available to Fellows and Candidate Fellows of
the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of
Pediatric Nurse Practitioners (NAPNAP) for 1.2
NAPNAP contact hours of which 0.0 contain
pharmacology (Rx) content. The AAP is designated
as Agency #17. Upon completion of the program,
each participant desiring NAPNAP contact hours
should send a completed certificate of attendance,
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The American Academy of Physician Assistants accepts
AMA PRA Category 1 Credit(s)TM from organizations
accredited by the ACCME .
Glenn Flores, MD, FAAP
Professor of Pediatrics and Public Health
Director, Division of General Pediatrics
The Judith and Charles Ginsburg Chair in Pediatrics
UT Southwestern Medical Center
Dallas, Texas
Learning Objectives
Upon completion of this activity, you will be able to:



Discuss racial/ethnic disparities in pediatric patient safety
and summarize priorities and unanswered questions in the
field.
Describe a new conceptual model for understanding
racial/ethnic disparities in pediatric patient safety.
Apply this model to improve patient safety for racial/ethnic
minority children.
Racial/Ethnic Disparities
and Patient Safety
Glenn Flores, MD, FAAP
Professor and Director, Division of General Pediatrics
Judith and Charles Ginsburg Chair in Pediatrics
University of Texas Southwestern Medical Center
Children’s Medical Center
Dallas, TX
Reference: Pediatric Clinics of North America
2006;53:1197-1215
Background


Number of racial/ethnic minority children will
exceed number of non-Latino white children in US
by 2030
Indeed, from 2030-2050, non-Latino white
population will contribute nothing to nation’s
population growth because it will decline in size,
in contrast to
 African-American population, which will double
between 1995 and 2050
 Latino population, which will add more people to
US every year after 2020 than all other
racial/ethnic groups combined
Background


Rapid growth of minorities in US makes it
increasingly likely each year that healthcare
providers will care for minority patients
Nevertheless, very little known about racial/ethnic
disparities in patient safety, particularly when it
comes to children. For example, in landmark
Institute of Medicine (IOM) report,
“To Err is Human:”
 Neither race nor ethnicity mentioned
 Linguistic issues mentioned very briefly in 3
sentences, and only in reference to access to
care or general recommendations
Webinar Goals



Review what we know about racial/ethnic
disparities in pediatric patient safety and
summarize priorities and unanswered
questions in this field
Describe new conceptual model for
racial/ethnic disparities in patient safety
Identify what can be done to improve
patient safety for racial/ethnic minority
children
Helpful Definitions
Because substantial variation exists in patient safety
terminology, it’s useful to define certain terms
 Medical error
 Act of commission or omission that
substantively increases risk of a medical
adverse event
 Can result from failure of planned action to be
completed as intended (i.e., mishap or error of
execution), or use of wrong plan to achieve aim
(i.e., error of planning)
Definitions


Error of commission
 Medical error resulting in inappropriate increased risk of
iatrogenic adverse event(s) from receiving too much or
hazardous treatment (overuse or misuse)
 Includes quality problems such as excessive medication
doses, contraindicated treatments, giving wrong
medication, or iatrogenic risk from unneeded interventions
Error of omission
 Medical error resulting in an inappropriate increased risk of
disease-related adverse event(s) from receiving too little
treatment (underuse)
 Includes quality problems such as delayed diagnoses,
subtherapeutic medication doses, and failure to provide
indicated treatments
Definitions

Medical adverse event
 Incident resulting in medical injury,
complication, worsening health outcomes, or
perceived harm (either physical or emotional
distress)
 Can occur despite appropriate care (such as
recognized complications of an intervention or
resulting from the person's underlying disease)
or can be caused by errors of omission or
commission
Definitions


Racial/ethnic disparity
 Any difference in health or healthcare among
different racial/ethnic groups (using whites as
reference group)
Linguistic disparity
 Any difference in health or healthcare between
those whose primary language is English (the
reference group) and those whose primary
language is not English and who are limited in
English proficiency (LEP, defined as self-rated
English speaking ability of less than
“very well”)
Review of Medical Literature



Systematic review performed of representative sample
of published literature on racial/ethnic disparities in
pediatric patient safety to
 Identify what’s known and not known about
racial/ethnic disparities in pediatric patient safety
 Summarize urgent priorities and unanswered
questions
Medline search of > 40 years of research (from 1966
to 2006) published in 14 major journals
Search criteria yielded 323 articles
Review of Medical Literature




Very few pediatric patient safety articles have
examined racial/ethnic disparities
Of 323 pediatric patient safety articles in
systematic review, only 9 (3%) included
race/ethnicity in analyses
Only 1 of 323 studies (0.3%) specifically focused
on racial/ethnic disparities in patient safety
(although it included both children and adults)
4 studies examined data for both children and
adults, but did not perform separate analyses for
children by race/ethnicity
Key Findings from Literature:
Disparities in Birth Trauma



Analysis of Healthcare Cost and Utilization Project (HCUP) State
Inpatient Databases (SIDs) revealed significantly higher risk of
birth trauma in minority newborns. Compared with white newborns,
adjusted odds of birth trauma
 1.5 times greater (95% confidence interval [CI], 1.5-1.6) for
African-American newborns
 1.2 times greater (95% CI, 1.1-1.2) for Latino newborns
 1.2 times greater (95% CI, 1.1-1.2) for newborns in other
racial/ethnic groups
Of note, birth trauma by far most common adverse medical event,
accounting for over 36,000 events and event rate of 154 per 10,000
discharges, exceeding event rate (100 per 10,000 discharges) for all
10 other adverse medical event categories combined
Newborns with birth trauma documented to have almost triple inhospital mortality rate of newborns without birth trauma
Key Findings: Disparities in
Infection Due to Medical Care


Analysis of Healthcare Cost and Utilization Project (HCUP)
State Inpatient Databases (SIDs) revealed
 African-Americans, Asians/Pacific Islanders, and Latinos
had significantly higher rates than whites of infections due
to medical care and of post-operative sepsis
Analysis of Healthcare Cost and Utilization Project (HCUP)
Nationwide Inpatient Sample documented
 African-Americans had higher risk than whites of
postoperative infectious complications, including sepsis,
and infections following infusion, injection, and
transfusion
 Latinos had somewhat higher risk than whites of
postoperative septicemia and infection due to medical care
Key Findings: Disparities in
Postoperative Adverse Medical Events

Analysis of Healthcare Cost and Utilization Project
(HCUP) State Inpatient Databases (SIDs) revealed that,
compared with white children,
 African-American children had significantly higher
rates of postoperative hemorrhage/hematoma,
decubitus ulcers, and pulmonary embolus or deep vein
thrombosis
 Asians/Pacific Islander children had significantly
higher rate of postoperative hemorrhage/hematoma
 African-Americans, Asians/Pacific Islanders, and
Latinos had significantly higher rates of postoperative
respiratory failure and physiologic/metabolic
derangement
Key Findings: Disparities in
Postoperative Adverse Medical Events

Analysis of Healthcare Cost and Utilization Project
(HCUP) Nationwide Inpatient Sample documented
that, compared with white children,
 African-American children had higher risk of
decubitus ulcers, infection following infusion,
injection, transfusion, postoperative physiologic
and metabolic derangements, and
thromboembolism
 Latino children had somewhat higher risk of
postoperative septicemia, respiratory failure, and
physiologic and metabolic derangements
Racial/Ethnic Differences in
Perceived Error Severity & Reporting
Survey of 499 parents in an ED revealed racial/ethnic
differences in parental perceptions of medical error severity
and parental preferences for reporting medical errors to a
disciplinary body. Compared with white parents,

African-American parents significantly more likely to rate
4 medical error scenarios as more severe (62% vs. 49%,
respectively; P < .01)

African-American parents significantly more likely to
want party responsible for medical error to be reported to
disciplinary organizations (50% vs. 33%; P < .01)
 Difference persisted even after adjustment for relevant
covariates (relative risk, 1.29; 95% CI,1.02-1.58).
Language Barriers and Higher
Risk of Adverse Events
Case-control study of 572 children hospitalized at a
children’s hospital documented disparities in risk of
adverse medical events for children whose families
requested Spanish interpreters
 Patients and families requesting Spanish
interpreters had more than twice the odds of
serious medical events (odds ratio, 2.26; 95% CI,
1.06-4.81) compared with those
not requesting interpreters
Unanswered Questions:
Disparities and Patient Safety




Many unanswered questions remain about
racial/ethnic disparities in pediatric patient safety
More research needed on racial/ethnic disparities in
birth trauma and reasons for disparities
Greater insight needed about minorities’ greater risk
for infections due to medical care and for
postoperative bleeding, sepsis, respiratory failure, and
physiologic/metabolic derangement
Not enough known about racial/ethnic disparities in
pediatric patient safety in outpatient setting
Unanswered Questions:
Disparities and Patient Safety


More research needed on association of
language barriers with medical errors and
adverse medical events
When medical errors and adverse medical
events occur, need to know more about
minorities’ perceptions and preferences
regarding severity, disclosure, reporting,
disciplinary response, and legal action
New Conceptual Model: Racial/
Ethnic Disparities in Patient Safety
New conceptual model proposed to provide more comprehensive,
patient- and family-centered framework for understanding
disparities in patient safety. Five components of model include:

Higher prevalence of known risk factors for medical errors in
minorities

Medical errors of omission and deviations from optimal
practice frequent and particularly important for minorities

Adverse medical event definitions often fail to include
important minority patient views on what constitutes harm

Language barriers result in higher risk of medical errors and
adverse medical events

Data collection systems for identifying and monitoring
disparities in patient safety often insufficient or absent
Higher Prevalence of Risk Factors
for Medical Errors in Minorities
1st component of model posits minority children at higher
risk for patient safety disparities due to high prevalence of
known risk factors for medical errors in minority children

Youngest hospitalized children (0-1 year olds) consistently
and significantly more likely to experience patient safety
events and youngest children (0-3 years old) at greatest
risk for outpatient medication errors

Minorities comprise substantially larger proportion of
youngest children (0-5 years old) in US than in general US
population: 43% of 20 million 0-5 year olds non-white,
compared with 32% of US population of all ages

Thus, youngest US children both more likely to be
minorities and to be at greater risk for medical errors and
adverse medical events
Higher Prevalence of Risk Factors
for Medical Errors in Minorities



Neonates in the Neonatal Intensive Care Unit (NICU)
experience highest rates of medication errors and potential
adverse drug events of any age group of hospitalized
children, and at rates exceeding those of general adult
population
African-Americans continue to have substantially higher
rates of premature, low birth weight, and very low birth
weight infants, accounting for their disproportionate
representation among NICU admissions (> ½ of NICU
admissions African-American)
Thus, African-American infants at high risk for medication
errors and potential adverse drug events because of
disproportionately greater risk of NICU admission
Higher Prevalence of Risk Factors
for Medical Errors in Minorities


Receiving care in ED has been shown to be
associated with higher risk of adverse medical
events
Multiple studies document that minority children
make significantly more ED visits than white
children
Importance of Errors of Omission
& Deviation from Optimal Practice




Recent work has called attention to importance of
medical errors of omission, in which receiving too
little treatment (under-use) results in inappropriate
increased risk of disease-related adverse medical
events
One study found omission errors accounted for 96%
of all medical errors
Most common categories of omission errors include
obtaining insufficient information from histories and
physicals, inadequacies in diagnostic testing, and
patients not receiving needed medications
We propose that medical errors of omission a frequent
and important patient safety issue for racial/ethnic
minority children, in comparison with white children
Importance of Errors of Omission
& Deviation from Optimal Practice


Multiple studies document medical errors of omission
among minority children and sometimes serious adverse
medical events they cause
Language barriers documented to frequently result in
insufficient information from histories and physicals for
Latino pediatric patients, including
 Omission of important information about drug
allergies, past medical history, and chief complaint
 Critical distortions in psychiatric symptoms
 Misinterpretations resulting in quadriplegia and
inappropriate placement of children in social services
custody for erroneous diagnosis of child abuse
Importance of Errors of Omission
& Deviation from Optimal Practice


Example of inadequacies in diagnostic testing:
study of children presenting to children’s hospital
ED which found Latino children significantly less
likely than white children to undergo two or more
diagnostic tests or to have x-rays done
Several studies both in US and UK document
substantial racial/ethnic disparities in pediatric
asthma treatment, such as significantly lower odds
of minorities receiving β2 agonists and antiinflammatory medications
Importance of Errors of Omission
& Deviation from Optimal Practice




Stark example of medical errors of omission: study of
white psychotherapists in which 2 case histories presented
that were identical except for race of adolescent boy
(white vs. African-American)
Compared with white adolescent’s case, psychotherapists
gave significantly lower ratings for African-American
adolescent for clinical significance of 8 of 21 pathological
behaviors
White therapists less distressed about African-American
adolescent beating his girlfriend, stealing cars, mistrusting
interviewer, and hating his mother
Supports hypothesis that mental disorders in AfricanAmerican adolescents under-diagnosed because their
pathological behaviors rated less severely
Importance of Errors of Omission
& Deviation from Optimal Practice



Importance of medical errors of omissions in patient
safety raises broader conceptual issue: medical error
should be defined as any deviation from optimal
practice
This critical adjustment in definition of medical error
allows powerful systems approach to error prevention
in which an error viewed as a system failure that
requires system adjustment
Including deviation from optimal practice as a
medical error also underscores crucial
interrelationship of patient safety, quality of care, and
racial/ethnic disparities
Importance of Errors of Omission
& Deviation from Optimal Practice



Deviation from optimal practice associated with higher
risk of serious adverse medical events for minorities and
may contribute substantially to disparities
Study of over 74,000 very low-birth-weight (VLBW)
infants in Vermont Oxford Network revealed minorityserving hospitals (those with >35% African-American
infants) had significantly higher adjusted infant mortality
rates for both African-American and white infants, vs.
hospitals serving <15% of African-American infants
Study of 51 New York hospitals documented hospitals
with >80% minority discharges had double adjusted odds
of adverse events due to negligence (injuries due to
interventions that were inappropriate or did not meet
standard of care), compared with hospitals with lower
proportions of minority discharges
Patient Safety Definitions Often Fail to
Include Minority Views on What Harm Is




Research reveals definitions of medical errors and adverse
medical events often fail to capture what constitutes harm and
error from perspectives of minority patients and families
Qualitative study of white and African-American patients
about preventable incidents resulting in perceived harm in
primary care and primary care of their children revealed 70%
of harms psychological
 For African-Americans, among most important incidents:
those in which racism or prejudice occurred
Findings suggest patients and families view breakdowns in
patient-physician relationship as more prominent medical
errors than technical errors in diagnosis and treatment
Failure to accommodate this patient-oriented definition of
medical error and harm, particularly regarding perceived
bias/prejudice towards minority patients, could lead to
ongoing but undetected disparities in patient safety
Language Barriers & Higher
Risk of Errors & Adverse Events



Evidence documents language barriers result
in higher risk of medical errors and
adverse medical events
Study of pediatric encounters with LEP Latino
children and their families revealed 63% of all
errors by medical interpreters had potential or
actual clinical consequences, with mean of 19
such errors per encounter
Errors committed by ad hoc interpreters (family
members and friends) significantly more likely to
be errors of potential clinical consequence than
those committed by hospital interpreters
(77% vs. 53%; P <.0001)
Language Barriers & Higher
Risk of Errors & Adverse Events

Errors of clinical consequence in this study included
 Omitting questions about drug allergies
 Omitting instructions on dose, frequency, and
duration of antibiotics and rehydration fluids
 Adding that hydrocortisone cream must be applied
to entire body, instead of solely to a facial rash
 Instructing a mother not to answer personal
questions
 Omitting that a child already swabbed for a stool
culture
 Instructing a mother to put amoxicillin in both ears
for treatment of otitis media
Language Barriers & Higher
Risk of Errors & Adverse Events
Study of over 4,000 children seen in ED showed that,
compared with English-proficient patients, LEP patients
who had either no interpreter or non-medical, ad hoc
interpreters, had:
 Significantly higher incidence of having medical tests
done (OR, 1.5; 95% CI, 1.04-2.2)
 Higher test costs (mean difference = $5.73)
 Significantly greater likelihood of hospitalization
(OR, 2.6; 95% CI, 1.4-4.5)
 Significantly greater likelihood of receiving
intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3)
Insufficient Data Collection Systems
and Patient Safety Disparities




Disparities in patient safety cannot be identified and
monitored if data collection systems fail to or inaccurately
record patients’ race/ethnicity, primary language spoken at
home, and English proficiency
Recent study revealed only 78% of US hospitals
systematically collect data on race/ethnicity of patients and
only 39% collect data on patients’ primary language
Just 27% of 1,000 hospitals surveyed, however, responded, so
these proportions actually may be substantially lower
51% of hospitals collecting race/ethnicity data reported that
admitting clerks determined patients’ race/ethnicity based on
observation, a method which
 Can result in high rates of inaccuracies, missing data, and
classifications in “unknown” and “other” categories
 Contradicts expert recommendations that such data be
collected by patient self-report
Insufficient Data Collection Systems
and Patient Safety Disparities



Another recent survey of 500 US hospitals found
that 78% collect patient race information, 50%
collect patient ethnicity information, and 50%
collect primary language information
Although recording language information highly
variable across hospitals and rarely a required
field
Survey non-response rate was 55%, so, as with
aforementioned survey, these proportions actually
may be substantially lower
Insufficient Data Collection Systems
and Patient Safety Disparities



These findings indicate that at least 22-50% of US
hospitals collect no patient race/ethnicity data and
50-61% collect no primary language data
Unclear whether any hospitals routinely collect
data on patients’ English proficiency, a measure
that has been shown to be more useful for
examining health outcomes
Such insufficiencies and absences in collection of
data on race/ethnicity and language can result in
failure to identify important patient safety
disparities
Two Illustrative Examples:
Asthma and Language Barriers


Pediatric asthma and language barriers
two of clearest and most well researched
examples of disparities in
pediatric patient safety
Next few slides examine patient safety
issues associated with asthma and
language barriers, using prior patient safety
work and definitions as well as
components of proposed conceptual model
Pediatric Asthma and Patient Safety



Disparities in pediatric asthma underscore important patient
safety issues and conceptual model components that may
perpetuate patient safety disparities
Studies document high prevalence of certain risk factors for
medical errors among minority children with asthma
Puerto Rican and African-American children experience
greater asthma severity and complexity
 Asthmatic children from both groups have significantly
higher adjusted odds than white asthmatic children of
suffering asthma attack in past year and experiencing more
severe wheezing
 African-American children substantially more likely than
white children to be hospitalized for and die from asthma
Pediatric Asthma and Patient Safety


Greater ED use another risk factor for medical errors
 Several studies document African-American and Latino
children significantly more likely to make asthma ED
visits than white children
Substantial literature documents frequent errors of
omission and deviation from optimal care for minority
children with asthma. Studies demonstrate minority
children with asthma significantly less likely than white
children with asthma to receive prescriptions for
 2 agonists
 Anti-inflammatory medications
 Medications and nebulizers for home use after hospital
discharge
Pediatric Asthma and Patient Safety



Studies also document minority children with asthma subject
to medical errors of commission, exposing them to
inappropriate increased risk of iatrogenic adverse events from
receiving too much or hazardous treatment (i.e., overuse or
misuse errors)
Among asthmatic children in UK, Afro-Caribbean asthmatic
children had 8 times the odds and Indian subcontinent children
4 times the odds of asthmatic white children of receiving
contraindicated antitussive prescriptions
African-American children with asthma in Washington state
Medicaid system found to have significantly higher adjusted
odds than white asthmatic children of receiving theophylline
prescriptions, which likely is misuse error representing
deviation from optimal therapy
Good News: Where There’s Cultural
Competency, There’s High Quality

Recent study of 1,663 asthmatic children in 5 health plans
in 3 states found practice sites with highest cultural
competency scores have
 Significantly lower patient under-use of preventive
asthma medications
(adjusted odds ratio of under-use = 0.15; 95% CI, 0.10.4)
 Significantly better parent ratings of
quality of asthma care
(Lieu et al. Pediatr. 2004;114:e102-10)
Language Barriers and Patient
Safety



Multiple studies document frequently serious medical errors
and adverse events that can occur due to language barriers
for limited English proficient (LEP) patients and their
families who fail to get trained medical interpreter services
Those who need but don’t get interpreters have poor selfreported understanding of diagnosis and treatment plan and
frequently wish healthcare providers explained things better
Ad hoc interpreters (family members, friends, untrained
bilingual staff, and strangers from waiting room or street)
 Misinterpret or omit up to ½ of all physicians’ questions
 More likely to commit errors with potential or actual
clinical consequences
 Have higher risk of not mentioning
medication side effects
 Ignore embarrassing issues when children interpret
Language Barriers and Patient
Safety
Interpreter errors in mental health care
shown to result in
 Overemphasis of psychotic features
 Under-emphasis of affective components
 Underestimation of suicide risk
 Distortions of intellectual abilities, mental status,
and thought disorders
 Difficulty assessing ambivalent patient attitudes
 “Normalization” of pathological symptoms
Language Barriers and Patient
Safety



Latino parents report lack of medical staff who speak
Spanish resulted in poor medical care for 8% of
children, misdiagnosis for 6% of children,
inappropriate medications for 5%, and inappropriate
hospitalizations for 1%
Children whose families request Spanish interpreters
have more than double the odds of serious medical
events compared with those not requesting interpreter
Study of pediatric ED visits demonstrated that,
compared with English-proficient patients, LEP
patients who had either no interpreter or non-medical,
ad hoc interpreters had significantly higher incidence
of having medical tests done, higher test costs, and
significantly greater likelihood of hospitalization and
receiving intravenous hydration
Language Barriers and Patient
Safety



Multiple published case reports dramatically illustrate
adverse medical events that can occur when language
barriers present
Six-week-old infant admitted for an overdose of
barbiturates due to a tenfold medication dosing error by an
LEP mother who did not understand outpatient dosing
instructions available only in English
Lack of medical interpreter resulted in delayed diagnosis
of appendicitis that ultimately evolved into ruptured
appendix, peritonitis, wound site infections, and 30-day
hospital stay
Language Barriers and Patient
Safety


2-year-old girl who sustained fractured clavicle by falling off
her tricycle misdiagnosed as victim of child abuse due to
misinterpretation of 2 words (“se pegó,” which can mean “she
hit herself” or “she was hit”)
 Girl and her sibling inappropriately subsequently placed in
social services custody after LEP mother was asked to sign
over voluntary custody using form only available in
English
Misinterpretation of single word (“intoxicado”) by paramedics
and ED staff resulted in comatose teen incorrectly being
treated and admitted for 48 hours for drug overdose
 Subsequently found to have ruptured cerebral artery,
resulting in quadriplegia and $71 million legal settlement
Language Barriers and
Patient Safety: Case


10-month-old girl taken to pediatrician’s office by her
monolingual Spanish-speaking parents and infant
diagnosed with iron-deficiency anemia. Pediatrician wrote
following prescription in English:
 Fer-In-Sol iron drops, 15 mg per 0.6 ml, 1.2 ml daily
(3.5 mg/kg)
Parents took prescription to pharmacy. With no available
interpreter, pharmacist attempted to demonstrate proper
dosing and parents nodded in understanding. Prescription
label on bottle written in English
Language Barriers and Patient
Safety: Case



Parents administered medication at home and,
within 15 minutes, 10-month-old vomited twice
and appeared ill
Parents took her to nearest ED, where serum iron
level 1 hour after ingestion = 365 mcg/dL
(therapeutic levels: 60-180 mcg/dL)
Upon questioning, parents stated they had
administered household tablespoon of medication,
approximately 15 ml or 43 mg/kg (a 12.5-fold
overdose)
Recent Research: Language Barriers,
Prescriptions, and Pharmacies
Recent study of pharmacies in major metropolitan area
revealed
 47% of pharmacies never/only sometimes can print
non-English-language prescription labels
 54% never/only sometimes can prepare
non-English-language information packets
 64% never/only sometimes can orally communicate
in non-English-languages
 11% use patient family members/friends to interpret
 Only 55% satisfied with their
LEP patient communication
Conclusions


Number of racial/ethnic minority children will exceed
number of non-Latino white children in US by 2030
 But very little known about racial/ethnic disparities
in patient safety, particularly in children
Review of medical literature revealed several
racial/ethnic disparities in pediatric patient safety,
including
 Higher rates of newborn birth trauma
 Infections due to medical care
 Postoperative adverse medical events
 Greater likelihood of adverse events for
hospitalized children whose parents requested
Spanish interpreter
Conclusions

Proposed new conceptual model for understanding
racial/ethnic disparities in patient safety includes 5
components
 Higher prevalence of risk factors for medical errors
 Frequent medical errors of omission
 Adverse medical event definitions that often fail to
incorporate minority views on what constitutes
harm
 Language barriers cause higher risk of errors and
adverse events
 Insufficient data collection systems for identifying
and monitoring racial/ethnic disparities
Implications/Take-Away Points



Need to identify and study means of reducing
greater minority risk of birth trauma
Need to be especially vigilant regarding
prevention, identification, and management of
postoperative infectious and non-infectious
complications among minorities
Given many adverse patient consequences of
language barriers, appropriate language services
always should be arranged for LEP patients and
families
Implications/Take-Away Points
Evidence suggests that improving patient safety
for minority children could be achieved by
 Routinely collecting and monitoring parental selfreported data on race/ethnicity, language, and English
proficiency
 Enhancing cultural competency of healthcare
providers and staff
 Providing adequate language services for all LEP
patients and their families