Improving Patient Safety Systems for Patients With Limited English Proficiency
- Institute of Medicine, Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
- Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
- Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in U.S. hospitals: a pilot study. Int J Qual Health Care 2007 Apr;19(2):60-67. Epub 2007 Feb 2.
- The Joint Commission. 2011 comprehensive accreditation manual for hospitals (CAMH): the official handbook. Update on the implementation plan for patient-centered communication standards. Oakbrook Terrace, IL: Joint Commission; 2010. Available at: www.jcrinc.com/common/PDFs/fpdfs/pubs/pdfs/JCReqs/JCP-08-10-S5.pdf.
- American Community Survey data accessed through American Factfinder. Suitland, MD: U.S. Census Bureau; 2009.
- John-Baptiste A, Naglie G, Tomlinson G, et al. The effect of English language proficiency on length of stay and in-hospital mortality. J Gen Intern Med 2004 Mar;19(3):221-8.
- Graham CL, Ivey SL, Neuhauser L. From hospital to home: assessing the transitional care needs of vulnerable seniors. The Gerontologist 2009 Feb 1;49(1):23-33.
- Jiang HJ, Andrews R, Stryer D, et al. Racial/ethnic disparities in potentially preventable readmissions: the case of diabetes. Am J Public Health 2005 Sep;95(9):1561-7.
- Ash M, Brandt S. Disparities in asthma hospitalization in Massachusetts. Am J Public Health 2006 Feb;96(2):358-62.
- Alexander M, Grumbach K, Remy L, et al. Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity. Am Heart J 1999 May;137(5):919-27.
- Wilson E, Chen AH, Grumbach K, et al. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med 2005 Sep;20(9):800-6.
- Traylor AH, Schmittdiel JA, Uratsu CS, et al. Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter? J Gen Intern Med 2010 Nov;25(11):1172-7.
- Price-Wise G. Language, culture, and medical tragedy: the case of Willie Ramirez. Health Affairs Blog 2008 Nov 19. Available at: healthaffairs.org/blog/2008/11/19/language-culture-and-medical-tragedy-the-case-of-willie-ramirez/.
- Quan K. The high costs of language barriers in medical malpractice. Berkeley: University of California School of Public Health, National Health Law Program; 2010. Available at: www.healthlaw.org/images/stories/High_Costs_of_Language_Barriers_in_Malpractice.pdf.
- Carbone E, Gorrie J, Oliver R. Without proper language interpretation, sight is lost in Oregon and a $350,000 verdict is reached. Legal Rev Commentary Suppl Healthcare Risk Manage 2003(May 1-3).
- The Joint Commission. 2011 comprehensive accreditation manual for hospitals (CAMH): the official handbook. Oakbrook Terrace, IL: Joint Commission; 2010. Available at: www.jcrinc.com/Joint-Commission-Requirements/Hospitals/.
- Diamond LC, Schenker Y, Curry L, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med 2009 Feb;24(2):256-62.
- Flores G, Rabke-Verani J, Pine W, et al. The importance of cultural and linguistic issues in the emergency care of children. Pediatr Emerg Care 2002 Aug;18(4):271-84.
- Ring DC, Herndon JH, Meyer GS. Case records of the Massachusetts General Hospital: case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. N Engl J Med 2010 Nov 11;363(20):1950-7.
- King HB, Battles J, Baker DP, et al. TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. Vol. 3: Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.
- Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf 2011 Aug;37(8):357-64.
- Mayer CM, Cluff L, Lin WT, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf 2011 Aug;37(8):365-74.
- Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010 Nov-Dec;67(6):439-43.
- Deering S, Rosen MA, Ludi V, et al. On the front lines of patient safety: implementation and evaluation of team training in Iraq. Jt Comm J Qual Patient Saf 2011 Aug;37(8):350-6.
- Improving patient safety through informed consent for patients with limited health literacy: an implementation report. Washington, DC: National Quality Forum; 2005.
- Cohen AL, Rivara F, Marcuse EK, et al. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics 2005 Sep;116(3):575-9.
- Interpreter/Translation Services Task Force. Language access in health care statement of principles. In: Effective communication in healthcare: interpreter/translation services for limited English proficiency populations in New Jersey. Princeton: New Jersey Hospital Association. Available at: www.njha.com/publications/pdf/Appendix_B_Language_Access_Need_Permission..., Accessed March 30, 2012.
- Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 2003 Jan;111(1):6-14.
- Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med 2007 Jun 28;356(26):2713-9.
- Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care 2004 Apr;13(2):145-51; discussion 151-2.
- Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003.
- Smedley BD. Expanding the frame of understanding health disparities: from a focus on health systems to social and economic systems. Health Educ Behav 2006 Aug;33(4):538-41.
- The Joint Commission. Sentinal event data: root causes by type. Available at: www.jointcommission.org/assets/1/18/
Root_Causes_Event_ Type_2004-3Q2011.pdf. Accessed December 14, 2011.
- Wilson-Stronks A, Galvez E. Hospitals, language, and culture: a snapshot of the nation. Exploring cultural and linguistic services in the nation's hospitals: a report of findings. Oakbrook Terrace, IL: The Joint Commission and California Endowment; 2007.
- Berube A, Frey W, Singer A, et al. State of metropolitan America: on the front lines of demographic transformation. Washington, DC: The Brookings Institution Metropolitan Policy Program; 2010.
- Humes K, Jones N, Ramirez R. Overview of race and Hispanic origin: 2010. Suitland, MD: U.S. Census Bureau; 2011. Available at: www.census.gov/prod/cen2010/briefs/c2010br-02.pdf.
- Donato KM, Tolbert II CM, Nucci A, et al. Recent immigrant settlement in the nonmetropolitan United States: evidence from internal census data. Rural Sociol 2007;72(4):537-59.
- Frey WH. Diversity spreads out: metropolitan shifts in Hispanic, Asian, and Black populations since 2000. Washington, DC: The Brookings Institution; 2006.
- Cheeseman Day J. Population profile of the United States: national population projections. Available at: www.census.gov/. Accessed September 2010.
- Suárez-Orozco MM, Páez M, David Rockefeller Center for Latin American Studies. Latinos: remaking America. Berkeley, CA: University of California Press; 2002.
- Sack K. Medicare won't pay for medical errors. New York Times, September 30, 2008, section A1.
- Centers for Medicare & Medicaid Services. Changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Federal Register 2008 Aug 19: 48433-49084. Available at: edocket.access.gpo.gov/2008/pdf/E8-17914.pdf.
- Centers for Medicare & Medicaid Services. CMS improves patient safety for Medicare and Medicaid by addressing never events. Fact Sheets 2008 Aug 4. Available at: www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3224&intNumPerPage=10&checkDate=&
- Report to Congress: reforming the delivery system. Baltimore, MD: Medicare Payment Advisory Commission; June 2008.
- Trosty RS. Limiting physician liability in treating diverse patient populations. Inova Health System Leadership Meeting, 2006.
- Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission; 2010. Available at: www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf.
- The Robert Wood Johnson Foundation. Improving quality of health care relies on effective language services. Washington, DC: George Washington University School of Public Health and Health Services; October 2007.
- Marx D. Patient safety and the "just culture": a primer for health care executives. New York, NY: Columbia University; 2001.
- Outcome Engenuity. The Just Culture Community. Available at: www.justculture.org/. Accessed October 24, 2011.
- Dingley C, Daugherty K, Derieg M, et al. Improving patient safety through provider communication strategy enhancements. In: Henriksen K, Battles J, Keyes M, et al, eds. Advances in patient safety: new directions and alternative approaches. Vol. 3. Performance and tools. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.
- Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003 Dec;12 Suppl 2:ii17-23.
- Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys. Qual Saf Health Care 2005 Oct;14(5):364-6.
- Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety. [
PDF version - 170.56 KB
] Accessed March 30, 2012.
- Pursuing an optimal culture of safety. Cambridge, MA: Controlled Risk Insurance Company/Risk Management Foundation; 2011.
- Ethics manual. Fourth edition. American College of Physicians. Ann Intern Med 1998 Apr 1;128(7):576-94.
- Council on Ethical and Judicial Affairs. Code of medical ethics: current opinions. Chicago, IL: American Medical Association; 2000.
- Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002 Feb 5;136(3):243-6.
- When things go wrong: responding to adverse events. A consensus statement of the Harvard hospitals. Burlington, MA: Coalition for the Prevention of Medical Errors; 2006.
- Massachusetts Executive Office of Health and Human Services. FY2007 inpatient hospital discharge database documentation manual. Boston, MA: Division of Health Care Finance and Policy; 2009.
- Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med 2009 Oct 1;361(14):1401-6.
- Agency for Healthcare Research and Quality. TeamSTEPPS®: National Implementation. Available at: http://teamstepps.ahrq.gov/about-2cl_3.htm.
- Norris WM, Wenrich MD, Nielsen EL, et al. Communication about end-of-life care between language-discordant patients and clinicians: insights from medical interpreters. J Palliat Med 2005 Oct;8(5):1016-24.
- Poss JE, Rangel R. Working effectively with interpreters in the primary care setting. Nurse Pract 1995 Dec;20(12):43-47.
- Wachter R. Understanding patient safety. New York: McGraw-Hill Professional; 2007.
- TeamSTEPPS® instructor guide. TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety. Developed by the Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; September 2006. AHRQ Publication No. 06-0020.
- Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev 2005 Jun;62(3):255-99.
- Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007 Apr;42(2):727-54.[AL4]
- Lindholm M, Hargraves JL, Ferguson WJ, et al. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012 Apr 18. [Epub ahead of print]