Language barriers and patient safety risks in hospital care. A mixed methods study
Introduction
A language barrier, which is a communication barrier resulting from the parties concerned speaking different languages, has been shown to be a threat to the quality of hospital care (Karliner et al., 2007). Patient safety is a prerequisite for good quality of care. We define safe hospital care as care where no harm is caused to patients by not following professional standards or by inadequate healthcare management resulting in adverse events such as misdiagnosis or adverse drug reactions. Patient safety risks are situations that potentially lead to adverse events. Several studies described the link between a language barrier and patient safety and Divi et al. showed that US patients with low English proficiency experienced more adverse events than patients with adequate English proficiency (Divi et al., 2007, Johnstone and Kanitsaki, 2006, Suurmond et al., 2010). Other studies showed adverse events associated with language barriers in specific domains in hospital care. For example, Wasserman et al. found that medication errors represented a larger share of adverse events for those patients who had a language barrier compared to those who did not (Wasserman et al., 2014).
Several international studies showed a lack of adequate detecting, reporting, and bridging of a language barrier (Karliner et al., 2007). International guidelines, such as the Joint Commission International, provide guidelines to overcome language barriers in their “Standards for hospitals” (JCIA, 2014). They state that: (1) patient education, follow-up instructions, and informed consent must be given in a language the patient can understand; (2) the hospital should seek to reduce language barriers; and (3) the patient's language must be assessed and noted in the patient record. The main accreditation system for quality of hospital care in the Netherlands does not contain standards explicitly related to language barriers (NIAZ).
Professional interpreters are considered the best bridge for a language barrier in health care (Karliner et al., 2007). Internationally, underuse of interpreters in healthcare was reported (Diamond et al., 2009, Schenker et al., 2011). A Dutch study convincingly showed underuse of professional interpretation services in general practice and another study using professional interpretation service data also suggests underuse in hospital care (Langendijk-van den Berg et al., 2014, Meeuwesen and Twilt, 2011). However, evidence on the underuse of professional interpreters in Dutch hospital care is lacking.
A Dutch record review cohort study among 1339 hospitalized patients assessing ethnic inequalities in adverse events in Dutch hospital care enabled us to investigate how language barriers were reported and bridged in Dutch hospital care, and to identify patient safety risks related to language barriers during hospitalization (Diamond et al., 2014, van Rosse et al., 2012). Since nurses and physicians have different tasks in the care process and play different roles, we analyzed patient safety risks during nursing care and during physician care separately. The following research questions were answered in this study:
- 1.
At which moments during hospitalization do language barriers constitute a risk for patient safety?
- 2.
How are language barriers detected and reported in hospital care?
- 3.
How are language barriers bridged in hospital care? What is the policy and what happens in practice?
Section snippets
Methods
This mixed-methods study was embedded in a cohort study to investigate ethnic inequalities in adverse event rates in four Dutch urban hospitals among 1339 hospitalized patients, of whom 576 were patients with an ethnic minority background whose data were used for the present study (Diamond et al., 2014, van Rosse et al., 2012, van Rosse et al., 2014). Patients were included in the cohort during their hospital admission on one of 30 participating wards (10 of which were surgical and 20
Results
Situations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient–physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were
Discussion
We found a wide variety of patient safety risks related to language barriers during the hospitalization of patients with low Dutch language proficiency. Several high-risk situations were found both in nursing and physician care. We found that language barriers were often not adequately reported in patient records, while our results suggest underuse of professional interpretation services. However, interpretation services cannot always be regarded a practical solution, for instance during short
Conclusion
The present study showed a wide variety of patient safety risks in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier which, in the first place, asks for adequate detecting and reporting of a language barrier. This is currently not sufficiently done in most Dutch hospitals. Moreover, new solutions to bridge language barriers are needed for situations in which a professional or even informal interpreter is not feasible, such
Conflict of interest
The authors report no conflicts of interest.
Funding
Funding by the Dutch Ministry of Health, Welfare, and Sports.
Ethical apporval
Ethical apporval by medical ethical committees of all participating hospitals.
Acknowledgments
This study was funded by the Dutch Ministry of Health, Welfare, and Sport. The authors would like to thank Ebru Ertekin for transcribing interviews.
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