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Article Reviews and Commentary

Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters.
Flores, Laws, Mayo et al. Pediatrics 2003;111:6-14

According to the 2000 US census approximately 45 million people speak a language other than English at home and 19 million have limited English proficiency (LEP). The number of US school-aged children who are LEP is 2.4 million, 5% of the total, an increase of 85% since 1979.

The authors of this paper audiotape 13 pediatric encounters in a hospital outpatient clinic in which a Spanish Interpreter was used. In 6/13 encounters, a professional interpreter was used. In the remaining 7 encounters, ad-Hoc interpreters were used including nurses, social workers and in one case an 11 year-old sibling of the patient. In the analysis of the audiotapes, interpreter errors were defined as any misrepresentation of an utterance that occurred in the clinical encounter. There were 5 categories of errors: omission, addition, substitution, editorialization and false fluency (use of an incorrect word/phrase or word/phrase that does not exist in the particular language). Deviations from word-for-word interpretations attributed to the use of medical jargon, idioms etc. were not considered interpreter errors. Six hours of audiotapes, 474 pages of transcripts and 49,513 words comprised the material that was reviewed. There were 3 bilingual reviewers, 2 physicians and one social worker.

The reviewers found a mean of 31 errors per encounter. The frequencies of the more common types is as follows; omission 52%, false fluency 16%, substitution13%, editorialization 10%, and addition 8%. Sixty-three (63%) of the errors had potential clinical consequences. Errors committed by ad-Hoc interpreters were significantly more likely to be of the type with potential clinical consequences than errors made by the professional interpreters. In this outpatient setting errors with clinical consequences included: 1) omission of questions about drug allergies; 2) omission of instructions on the dose, frequency and duration of antibiotic administration; 3) omission of instructions about duration of oral rehydration fluid administration 4) instruction to the mother not to answer personal questions; 5) instructing a mother to put amoxicillin into both ears for treatment of otitis media.

The authors conclude that, given the greater frequency of interpreter errors and especially interpreter errors of clinical significance, trained interpreters should be available for families who are LEP.

Commentary
Thomas J. Mancuso, MD, FAAP

This paper should not surprise those of us who care for families with limited proficiency in English at all. Communication is difficult enough when all parties are fluent in the same language and of similar educational backgrounds. As shown in the preceding paper about parent satisfaction with medical care for their children, the areas where problems were most frequent involved communication. Even when everyone involved is proficient in English, the informed consent process for the provision of anesthesia is so often inadequate, being reduced to obtaining a signature on a form. In cases of families with LEP, this paper makes the strong case that not only should we use trained professional interpreters, but also redouble our efforts to be certain that the families and children are actively participating in the informed consent process before administering anesthesia to the child.

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