Appendix B: Bringing It To Life: Case Study
The following case study is adapted from our TeamSTEPPS® LEP Module: Enhancing Safety for Patients
With Limited English Proficiency. This case highlights a situation that could have occurred in any hospital around the country. It is important to focus on the processes of care that do or do not occur leading to poor communication, misunderstanding, and potential patient safety events that are readily preventable. A video will be available on CD and on the Web site at www.ahrq.gov/teamsteppstools/.
Mr. Rafael Hernandez, a 45-year-old Spanish-speaking man with type 2 diabetes and no other major
medical issues, presents to the emergency department (ED) at a local hospital accompanied by his wife. His first encounter is with the registrar, who asks him in English why he came to the ED today. He tells her that he is having “fatiga” and that he needs to be seen. His English is difficult to understand but the symptom seems clear enough. The registrar takes down his information as best as possible and asks him to
wait for the triage nurse.
After 20 minutes, Mr. Hernandez sees the nurse, who asks again in English what brings him to the hospital.
Mr. Hernandez: I have... fatiga... you know how you say in English... Fatiga.
Nurse: OK, how long have you been fatigued?
Mr. Hernandez: I have fatiga. Very much. It happen in the morning.
Nurse: OK, so you have been tired since this morning. Do you have any other symptoms? Any fevers or chills?
After several more questions, the nurse goes on to explain that the ED is very busy today and he may
have to wait a while before seeing a physician, but he will be seen. She is surprised that he would come to the emergency room for a complaint like fatigue, which should be managed on an outpatient basis by his
primary care provider.
After 60 minutes, Mr. Hernandez has not yet seen a physician, prompting him to ask if he can see someone soon. About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.
Feeling that he is already bothering the ED staff, he avoids telling anyone about this.
The doctor arrives and begins asking a similar set of questions but in more detail. The doctor uses more complicated terms, and it becomes clear that Mr. Hernandez is not able to communicate well enough in
English to provide an accurate medical history. The doctor calls for an interpreter, who arrives 20 minutes later.
After a few minutes of discussion, the interpreter realizes that there has been a misunderstanding, and the word “fatiga” was not referring to “fatigue” but rather to “shortness of breath.” Since shortness of breath is a much more concerning symptom than fatigue, the doctor immediately orders an EKG. This shows that in fact the patient is having a myocardial infarction.
The doctor returns and, through the interpreter, begins to explain the situation to Mr. Hernandez and his wife. He is going to need an angioplasty and possibly a stent to help save his heart muscle. After describing the risks and benefits of the procedure, she asks if Mr. Hernandez understands. He says he does, but the interpreter is skeptical. The discussion was very fast and complicated, and Mr. Hernandez may have felt uncomfortable voicing his concerns. However, the interpreter does not feel it is her role to intervene. The doctor asks if Mr. Hernandez has any allergies to IV contrast dye, and he says he does not, but again, it is not clear that he understands what this means.
Several hours after his initial presentation to the ED, Mr. Hernandez is taken to the cardiac catheterization lab to undergo what should be a routine balloon angioplasty and stenting of a blocked coronary artery. An hour later, the nurse appears again and finds Mrs. Hernandez in the waiting room anxious and concerned. The interpreter is no longer present, but the nurse proceeds to explain:
Mrs. Hernandez, unfortunately your husband had a very bad allergic reaction to the intravenous contrast that we use for the cardiac catheterization. We were not able to complete the procedure and he had to be taken to the intensive care unit. He told us that he had no allergy to IV contrast dye, didn’t he?
As we have highlighted throughout this guide, patient safety events are generally not caused by one
specific or well-defined error. They are the result of a breakdown in communication and gaps in systems
of care on many levels. This case exemplifies that breakdown in a way that will most likely be familiar
to most who work in a health care setting. We will walk through these step by step to understand what
happened and how Mr. Hernandez’s care was compromised.
- Registrar did not recognize that the patient was LEP and did not relay this information to the clinical team.
This initial problem may have led to a delay in the triage process and to a long delay in obtaining a
qualified medical interpreter. However, blame for this should not fall on the shoulders of one individual
registrar. It is likely that she was never trained on how to identify a patient’s language needs, how to
record this information in the medical record, or how to communicate it to the clinical team either
verbally or through a standard flagging system.
This problem highlights the need for systematic collection of racial and ethnic data, language
preference, and English proficiency, which is absolutely necessary to adapt current systems to better
identify medical errors in LEP patients. It is doubtful a systematic process of calling for an interpreter
existed that could be initiated by the registrar alone or in quick consultation with the care team.
Registrars may be the first point of contact with an LEP patient. To ensure safe care for LEP patients,
they must be included in a team-based approach to identifying and addressing language needs.
- Triage nurse did not recognize the need for a qualified medical interpreter.
The next level of missed opportunity occurred at the level of the triage nurse. The situation here is similar to that of the registrar. However, in this case, the assumption that effective communication is occurring without an interpreter leads to the first major safety issue. By not recognizing that by “fatiga” the patient means “shortness of breath,” the nurse triages Mr. Hernandez to a low-acuity section of the ED, causing a long delay in his care. If an interpreter had already been assigned to the patient, or if the nurse had called for an interpreter immediately, this situation may have been avoided or mitigated. Again, this requires a system in place, a set of processes and education around these processes so that it is not a voluntary decision by a clinician who is already pressed for time but rather, the standard of care. This problem highlights the importance addressing root causes to prevent medical errors among LEP patients by
training staff on the use of interpreter services and cultural competency.
- Physician does not work effectively with the interpreter.
Although the physician eventually realizes that she is not able to obtain an accurate history from the patient and calls for an interpreter, she does not work effectively with the interpreter. This problem highlights the need to address root causes to prevent medical errors among LEP patients by training providers on interpreter use, cultural competency, and patient advocacy. Again, the goal is not to blame the individual but to understand the processes needed to provide safe care for LEP patients.
The physician could have improved her interaction with the interpreter and the care team in at least two major ways:
- She could have created a safe environment for effective communication by starting out with a brief
“huddle” with the interpreter and the nurse during which she summarized the clinical situation. This may have allowed the interpreter to feel empowered to speak up when she felt the patient did not
understand the physician.
- She could have learned certain skills for how to work effectively with an interpreter, such as speaking as clearly as possible, minimizing medical jargon, pausing after every sentence to allow for the
interpretation, and checking patient understanding through a method such as teach-back (go to resources
in Appendix E).62, 63 Had she done this, she may have realized that the patient had no idea what a contrast dye allergy was and that he in fact had experienced a severe reaction to contrast after a CT scan many years ago.
- Interpreter does not speak up when she realizes that the patient does not understand.
The interpreter does a good job early in this interaction to identify the miscommunication around the
word “fatiga.” In this context, she is acting as a patient safety advocate, not just an interpreter. However, she later allows the care team to proceed with the cardiac catheterization even though she suspects that the patient does not understand the procedure or the question about contrast dye allergy.
This problem highlights two areas: (1) the need to foster a supportive culture for safety of diverse
patient populations and thus ensure that staff are comfortable identifying issues, and (2) the need to
improve reporting of medical errors for LEP patients by training staff on when to report and how to report effectively, and ensuring that they are empowered to do so.
Since interpreters often feel intimidated by the clinical care team, they may hesitate to speak up when
they see a potential safety issue. It is crucial for the entire care team to create a safe environment for the identification of miscommunication or misunderstanding with LEP patients, particularly for interpreters who may be considered lower in the medical hierarchy. At the same time, interpreters need to feel
empowered as to their important role in this regard.
If Mr. Hernandez’s interpreter had spoken up in this case about the contrast allergy, a simple
premedication regimen could have prevented the severe allergic reaction and allowed him to receive the
angioplasty that could have prevented injury to his heart. The TeamSTEPPS LEP Module details more specific structured communication tools (e.g., SBAR and CUS words) to foster team communication and LEP patient safety.64, 65
While this case may seem extreme, research shows that errors like these occur more frequently for LEP patients when interpreters are not involved in care.66, 67 Other examples may include patients taking medications incorrectly due to misunderstanding discharge instructions or refusing important procedures because of a lack of clear explanation. By resensitizing ourselves to the importance of effective communication with LEP patients, we can develop a culture of patient safety that will prevent errors like these from occurring. Ultimately, hospitals must routinely monitor patient safety for LEP patients so that they can track these situations and learn from errors that occur, with an eye toward prevention in the future.
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