Cases & Commentaries

Language Barrier

Commentary By Glenn Flores, MD

The Case

A previously healthy 10-month-old girl was taken to a
pediatrician's office by her monolingual Spanish-speaking parents when they
noted that their daughter had generalized weakness. The infant was diagnosed
with iron-deficiency anemia. At the time of the clinic visit, there were no Spanish-speaking staff or interpreters available.
One of the nurses spoke broken Spanish and in general terms was able to
explain the girl had "low blood" and needed to take a medication.

The parents were thankful for the attention and nodded in
understanding. The pediatrician wrote the following prescription in English:

iron, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)

The parents took the prescription to the pharmacy. The local
pharmacy did not have a Spanish-speaking pharmacist on staff, nor did they
obtain an interpreter. The pharmacist attempted to demonstrate proper dosing
and administration using the medication dropper and the parents nodded in
understanding. The prescription label on the bottle was written in English.

The parents administered the medication at home and, within
15 minutes, the 10-month-old vomited twice and appeared ill. They took her to
the nearest emergency department, where the serum iron level 1 hour after
ingestion was found to be 365 mcg/dL
(therapeutic levels are 60-180 mcg/dL)
. She
was admitted to the hospital for intravenous hydration and observation.
Serial serum iron levels and electrolytes were monitored. She was
asymptomatic for the remainder of the hospitalization and discharged the
following day with no apparent sequelae.

Upon questioning, the parents stated that they had
administered a household tablespoon of the medication, approximately 15 ml or
43 mg/kg (a 12.5-fold overdose). At the time of discharge from the hospital,
the nurse counseled the parents on proper dosing through a hospital

The Commentary

Unfortunately, cases in which language barriers cause
compromised quality of care and preventable medical errors may become
increasingly common in the United
States. Almost 50 million Americans speak
a primary language other than English at home, and 22.3 million have limited
English proficiency (LEP), defined as a self-rated English-speaking ability
of less than "very well."(1)
The last decade witnessed a 47% increase in the number of Americans speaking
a non–English language at home and a 53% increase in the number of LEP
Americans.(2,3) Between 1980 and 2000, both of these
populations more than doubled, whereas the overall US population increased
only 25%.(2) Unfortunately, nearly half of LEP
patients needing medical interpreters do not get them (4), and only 23% of hospitals provide
training for staff on working with interpreters.(5) Americans' foreign language skills
are dismal: less than half of US high school students are enrolled in foreign
language courses.(6)

In the case description, we are told that neither bilingual
staff nor interpreters were available for this clinic visit. Having access to
trained medical interpreters or bilingual providers facilitates optimal
communication, patient satisfaction, and outcomes and reduces interpretation
errors for LEP patients and their families.(7)
In addition, a Title VI guidance memorandum issued by the Department of
Health and Human Services (DHHS) Office of Civil Rights states that the
denial or delay of medical care for LEP patients due to language barriers
constitutes a form of discrimination and requires recipients of Medicaid or
Medicare to provide adequate language assistance to LEP patients.(8) This case underscores the importance of having appropriate
language services available for LEP patients and their families, particularly
in settings with high volumes of LEP patients.

This case also highlights
the dangers of using ad hoc interpreters, defined as family members, friends,
untrained staff, or strangers from the waiting room or the street. Ad hoc
interpreters are significantly more likely to commit interpretation errors in
general and, in particular, errors with potential or actual negative clinical
consequences.(9) Ad hoc
interpreters are less likely to tell patients about medication side effects
and more likely to misinterpret or omit questions asked by physicians.(7) Moreover, their use results
in significantly lower patient and physician satisfaction than other
interpretation strategies.(7)

It is especially dangerous for children to interpret. They
frequently are embarrassed by and tend to ignore questions about
menstruation, bowel movements, and other bodily functions and are more likely
to make interpretation errors with potential or actual clinical consequence.(7) One study comparing hospital interpreters and ad hoc
interpreters, for example, found that when an 11-year-old sibling interpreted
during a pediatric visit, 84% of the 58 errors she committed had potential
clinical consequences.(9)
Child interpreters also are less likely to have complete command of two
languages, and their use may result in parents avoiding discussion of
sensitive subjects such as domestic violence, sexual issues, or drug and
alcohol abuse. The dangers of children interpreting prompted a bill currently
being considered by the California State Assembly (AB 775 [2005]) which would
ban using children as medical interpreters.

The disaster that
occurred in this case also could have been averted had the pharmacy provided
appropriate language services. Not enough attention has been paid to language
barriers and patient safety in pharmacies and prescription labels. A recent
study of all 161 pharmacies in the Bronx, NY
(a borough with a large Spanish-speaking population) revealed that 31% could
not provide prescription labels in Spanish, such labels were provided only if
the patient requested them, and the computer program at one chain pharmacy
could not translate common prescription terms such as "dropperful"
or "for thirty days."(10) Work by our research group showed that about
half of Milwaukee pharmacies never, or only sometimes, can print
non–English-language prescription labels, prepare non–English-language
information packets, or orally communicate with LEP patients; almost half are
dissatisfied with their LEP patient communication; and 1 in 9 pharmacies use
family members or friends to interpret.(11) A bilingual pharmacist, interpreter, or computer translation software
could potentially have prevented the patient safety mishap in this case,
underscoring the critical role pharmacists [See related Perspective] can play in overcoming the adverse clinical
consequences of language barriers.

Language barriers were
first identified as a patient safety issue in 2003.(
9) Very little research has been
conducted on language barriers as a cause of medical errors, so we do not
know how common such errors are, nor what kinds of errors occur in inpatient
and outpatient settings. A recent study revealed that Spanish-speaking
pediatric inpatients requesting an interpreter had more than double the odds
for serious medical events compared with patients not requesting an
A major problem is that data are not routinely collected on patients' English
proficiency and the primary language spoken at home. Recent analyses of 80
federal statutes, regulations, policies, and procedures revealed no statutes
that expressly prohibit collection of patients' primary language data;
however, none of the regulations require or even mention collecting such
data, either.(13)

High-profile cases are accumulating of medical errors due to
language barriers. Lack of an interpreter for a 3-year-old girl presenting to
the emergency department with abdominal pain resulted in several hours' delay
in diagnosing appendicitis, which later perforated, resulting in peritonitis,
a 30-day hospitalization, and two wound site infections.(14)
A resident's misinterpretation of two Spanish words (se pegó misinterpreted as "a girl was hit by someone
else" instead of "the girl hit herself" when she fell off her tricycle)
resulted in a 2-year-old girl with a clavicular
fracture and her sibling mistakenly being placed in child protective custody
for suspected abuse for 48 hours.(
Misinterpretation of a single Spanish word (intoxicado
misinterpreted in this case to mean "intoxicated" instead of its intended
meaning of "feeling sick to the stomach") led to a $71 million dollar
malpractice settlement associated with a potentially preventable case of

What can clinics, hospitals, and pharmacies do to ensure that
adequate language services are available for LEP patients and their families?
The Table details the various options
available. In situations where LEP patients are encountered infrequently, or
for rare language groups, the most cost-effective options might include
telephone interpreters, language bank cooperatives shared with other
practices, community-based organizations, or trained volunteers from local
universities.(16) For
clinics and hospitals caring for larger LEP populations, trained
interpreters, bilingual clinicians, trained bilingual staff, translation of
frequently used written materials, telephone interpreters, and telemedicine
linkups should be considered. Pharmacies should have computer translation
software for printing prescription labels and translated written materials
regarding instructions, side effects, and warnings available in all commonly
encountered non–English languages. Bilingual staff or interpreters would
additionally ensure optimal quality of care, and telephone interpreters may
prove useful for pharmacies with low numbers of LEP patients and for rare
language groups. For more information on issues such as providing language
services in smaller group practices, implementing cost-effective language
services when resources are limited, developing an individualized language
services access plan, and addressing multiple language needs, readers can
consult the Health Care Language Services Implementation Guide, which
will soon be released by the US Department of Health and Human Services.

Even when medical interpreters
and bilingual staff are available, a few simple steps may help clinicians and
interpreters reduce medication errors for LEP patients. Before being
discharged from the clinic, hospital, or pharmacy, LEP patients and their
families should always be asked to repeat back the name, dose, dose
frequency, duration of administration, and possible adverse reactions for all
prescribed medications and therapies. For optimal safety, especially when
medication dosing is potentially confusing, LEP patients and/or families
should perform a practice or actual dosing of the medication (with liquid
medication syringes marked at the appropriate dosing level) under the
observation of the clinician and pharmacist. Such directly observed dosing
has been shown to enhance safety and accuracy even when language barriers
exist.(17) Detailed written materials about
medications and their dosing can be prepared in the patient's language using
translators or computer software available to clinicians and pharmacists. As
with patients who speak English, patient safety is greatest for LEP patients
when provider-patient communication is optimized.

Take-Home Points

  • Optimal communication,
    patient satisfaction, and outcomes and the fewest interpreter errors
    occur when LEP patients and their families have access to trained
    medical interpreters or bilingual providers.
  • Clinicians should ask
    patients and parents about the primary language spoken at home, assess
    English proficiency, and obtain a trained medical interpreter for those
    who have LEP.
  • All clinics,
    hospitals, and pharmacies should have policies and procedures in place
    and know what to do when LEP patients need language services.
  • Medication labels and
    instructions should always be available in the patient's and family's
    primary language.

Glenn Flores, MD
Director, Center for the Advancement of Underserved Children
Associate Professor of Pediatrics, Epidemiology, and Health Policy
Medical College of WisconsinChildren's Hospital of Wisconsin


1. US Census
Bureau. Selected social characteristics: 2004. Available at:
Accessed March 20, 2006.

2. Shin
HB, Bruno R. Language use and English-speaking ability: 2000. US Census
Bureau Web site. Available at:
Accessed March 20, 2006.

3. US Census
Bureau. DP-2. Social Characteristics: 1990. Available at: DEC_1990_STF3_DP2&ds_name=DEC_1990_STF3_&geo_id=01000US.
Accessed March 20, 2006.

4. Baker
DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of
interpreters in an emergency department. JAMA. 1996;275:783-788.
[go to PubMed]

Ginsberg C, Martin V, Andrulis D, Shaw-Taylor Y,
McGregor C. Interpretation and Translation Services in Health Care: A Survey
of US Public and Private Teaching Hospitals. Washington, DC:
National Public Health and Hospital Institute; 1995:1-49

6. NationalCenter for Education Statistics. Table
57: Enrollment in foreign language courses compared with enrollment in grades
9 to 12 in public secondary schools: Selected years,
fall 1948 to fall 2000. Available at:
Accessed March 20, 2006.

7. Flores G. The impact of medical interpreter services on
the quality of health care: a systematic review. Med Care Res Rev. 2005;62:255-299.
[go to PubMed]

Guidance memorandum: Title VI prohibition against national origin
discrimination—persons with limited-English proficiency [Office for Civil
Rights Web site]. January 29, 1998. Available at:
Accessed March 29, 2006.

9. Flores
G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their
potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6-14.
[go to PubMed]

10. Sharif I, Lo S, Ozuah PO. Availability of Spanish prescription labels. J
Health Care Poor Underserved. 2006;17:65-69.
[go to PubMed]

11. Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. Pediatrics. 2007;120:e225-e235.
[go to PubMed]

12. Cohen
AL, Rivara F,
Marcuse EK, McPhillips H, Davis R. Are language barriers associated
with serious medical events in hospitalized pediatric patients? Pediatrics.
[go to PubMed]

13. Youdelman M, Hitov S. Racial,
Ethnic and Primary Language Data Collection: An Assessment of Federal
Policies, Practices and Perceptions. Vol 2. Washington, DC:
National Health Law Program; 2001.

14. Flores G, Abreu M, Schwartz
I, Hill M. The importance of language and culture in pediatric care: case
studies from the Latino community. J Pediatr. 2000;137:842-848.
[go to PubMed]

15. Harsham P. A misinterpreted word worth $71 million. Med
Econ. June 1984;61:289-292.

16. Flores G, Mendoza FS. ¿Dolor aquí?
¿Fiebre?: a little
knowledge requires caution. Arch Pediatr Adolesc Med. 2002;156:638-640.
[go to PubMed]

17. McMahon SR, Rimsza
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[go to PubMed]


Table. Suggested Options for Providing Adequate
Language Services to Limited English Proficiency (LEP) Patients

Interpretation of Spoken Word

Translating Written Patient Information

Translating Prescription Labels

Bilingual providers



medical interpreters

translation software

translation software

Telephone interpreter services

translation downloads from federal Web sites?


Bilingual staff



bank cooperative or group purchasing of interpreter services by



members of community-based organizations



simultaneous interpreters*



volunteers from local universities



Telemedicine linkups to interpreters



language immersion courses for clinicians and staff



*Patient and/or family members and clinician use headphones to communicate
via an offsite interpreter.

?For example, see: