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Racial/Ethnic Disparitiesand Patient Safety
Thursday, November 15, 200712:00 – 1:00 p.m. ET
Moderator: Erin R. Stucky, MD, FAAPPediatric HospitalistChildren’s Specialists of San DiegoRady Children’s HospitalSan Diego, California
This activity was funded through an educational grant from the Physicians’
Foundation for Health Systems Excellence.
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004).
The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.
All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.
The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.
DISCLOSURES Activity Title: Safer Health Care for Kids - Webinar Racial/Ethnic Disparities and Patient Safety Activity Date: November 15, 2007
DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant Financial
Relationship(s) (If yes, please list: Research Grant,
Speaker’s Bureau, Stock/Bonds
excluding mutual funds, Consultant,
Other - identify)
CME Content Will Include
Discussion/ Reference to Commercial
Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Glenn Flores, MD, FAAP
No No No No
DISCLOSURESSAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing health care goods
or services)
Nature of Relevant Financial Relationship(s)
(If yes, please list: Research Grant, Speaker’s
Bureau, Stock/Bonds excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include Discussion/
Reference to Commercial Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses
of Products AAP CME faculty are required to
disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Karen Frush, MD, FAAP (PAC Member)
No No No No
Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member)
No No No No
Christopher Landrigan, MD, MPH, FAAP (PAC Member)
No No No Not sure
Marlene R. Miller, MD, MSc, FAAP (PAC Chair)
No No No No
Paul Sharek, MD, MPH. FAAP (PAC Member)
No No No No
Erin Stucky, MD, FAAP (PAC Member)
No No No No
Nancy Nelson (AAP Staff) No No No No
Melissa Singleton, MEd (Project Manager – AAP Consultant)
No No No No
Junelle Speller (AAP Staff) No No No No
Rev 9/2007
DISCLOSURESAAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing health care goods
or services)
Nature of Relevant Financial Relationship(s)
(If yes, please list: Research Grant, Speaker’s
Bureau, Stock/Bonds excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include Discussion/
Reference to Commercial Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses
of Products AAP CME faculty are required to
disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Ellen Buerk, MD, FAAP
No No No No
Meg Fisher, MD, FAAP
No No No No
Robert A. Wiebe, MD, FAAP
No No Not sure No
Jack Dolcourt, MD, FAAP
No No No No
Thomas W. Pendergrass, MD, FAAP
No No No No
Beverly P. Wood, MD, FAAP No No No No
CME CREDIT
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credit.
This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.
The American Academy of Physician Assistants
accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .
Glenn Flores, MD, FAAPProfessor of Pediatrics and Public HealthDirector, Division of General PediatricsThe Judith and Charles Ginsburg Chair in PediatricsUT Southwestern Medical CenterDallas, Texas
Learning Objectives
Upon completion of this activity, you will be able to:
Discuss racial/ethnic disparities in pediatric patient safety and summarize priorities and unanswered questions in the field.
Describe a new conceptual model for understanding racial/ethnic disparities in pediatric patient safety.
Apply this model to improve patient safety for racial/ethnic minority children.
Glenn Flores, MD, FAAP Professor and Director, Division of General Pediatrics
Judith and Charles Ginsburg Chair in Pediatrics University of Texas Southwestern Medical Center
Children’s Medical CenterDallas, TX
Reference: Pediatric Clinics of North America
2006;53:1197-1215
Racial/Ethnic Disparities
and Patient Safety
Background Number of racial/ethnic minority children will exceed
number of non-Latino white children in US by 2030 Indeed, from 2030-2050, non-Latino white population will
contribute nothing to nation’s population growth because it will decline in size,in contrast to African-American population, which will double
between 1995 and 2050 Latino population, which will add more people to US
every year after 2020 than all other racial/ethnic groups combined
Background Rapid growth of minorities in US makes it increasingly
likely each year that healthcare providers will care for minority patients
Nevertheless, very little known about racial/ethnic disparities in patient safety, particularly when it comes to children. For example, in landmark Institute of Medicine (IOM) report,“To Err is Human:” Neither race nor ethnicity mentioned Linguistic issues mentioned very briefly in 3 sentences,
and only in reference to access to care or general recommendations
Webinar Goals Review what we know about racial/ethnic
disparities in pediatric patient safety and summarize priorities and unanswered questions in this field
Describe new conceptual model for racial/ethnic disparities in patient safety
Identify what can be done to improve patient safety for racial/ethnic minority children
Helpful Definitions
Because substantial variation exists in patient safetyterminology, it’s useful to define certain terms Medical error
Act of commission or omission that substantively increases risk of a medical adverse event
Can result from failure of planned action to be completed as intended (i.e., mishap or error of execution), or use of wrong plan to achieve aim (i.e., error of planning)
Definitions Error of commission
Medical error resulting in inappropriate increased risk of iatrogenic adverse event(s) from receiving too much or hazardous treatment (overuse or misuse)
Includes quality problems such as excessive medication doses, contraindicated treatments, giving wrong medication, or iatrogenic risk from unneeded interventions
Error of omission Medical error resulting in an inappropriate increased risk of disease-
related adverse event(s) from receiving too little treatment (underuse)
Includes quality problems such as delayed diagnoses, subtherapeutic medication doses, and failure to provide indicated treatments
Definitions Medical adverse event
Incident resulting in medical injury, complication, worsening health outcomes, or perceived harm (either physical or emotional distress)
Can occur despite appropriate care (such as recognized complications of an intervention or resulting from the person's underlying disease) or can be caused by errors of omission or commission
Definitions Racial/ethnic disparity
Any difference in health or healthcare among different racial/ethnic groups (using whites as reference group)
Linguistic disparity Any difference in health or healthcare between those
whose primary language is English (the reference group) and those whose primary language is not English and who are limited in English proficiency (LEP, defined as self-rated English speaking ability of less than“very well”)
Review of Medical Literature Systematic review performed of representative sample
of published literature on racial/ethnic disparities in pediatric patient safety to Identify what’s known and not known about
racial/ethnic disparities in pediatric patient safety Summarize urgent priorities and unanswered
questions Medline search of > 40 years of research (from 1966 to
2006) published in 14 major journals Search criteria yielded 323 articles
Review of Medical Literature Very few pediatric patient safety articles have
examined racial/ethnic disparities Of 323 pediatric patient safety articles in systematic
review, only 9 (3%) included race/ethnicity in analyses
Only 1 of 323 studies (0.3%) specifically focused on racial/ethnic disparities in patient safety (although it included both children and adults)
4 studies examined data for both children and adults, but did not perform separate analyses for children by race/ethnicity
Key Findings from Literature: Disparities in Birth Trauma
Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed significantly higher risk of birth trauma in minority newborns. Compared with white newborns, adjusted odds of birth trauma
1.5 times greater (95% confidence interval [CI], 1.5-1.6) for African-American newborns
1.2 times greater (95% CI, 1.1-1.2) for Latino newborns 1.2 times greater (95% CI, 1.1-1.2) for newborns in other racial/ethnic
groups Of note, birth trauma by far most common adverse medical event,
accounting for over 36,000 events and event rate of 154 per 10,000 discharges, exceeding event rate (100 per 10,000 discharges) for all 10 other adverse medical event categories combined
Newborns with birth trauma documented to have almost triple in-hospital mortality rate of newborns without birth trauma
Key Findings: Disparities in Infection Due to Medical Care
Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed
African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates than whites of infections due to medical care and of post-operative sepsis
Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented
African-Americans had higher risk than whites of postoperative infectious complications, including sepsis, and infections following infusion, injection, and transfusion
Latinos had somewhat higher risk than whites of postoperative septicemia and infection due to medical care
Key Findings: Disparities in Postoperative Adverse Medical Events
Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed that, compared with white children,
African-American children had significantly higher rates of postoperative hemorrhage/hematoma, decubitus ulcers, and pulmonary embolus or deep vein thrombosis
Asians/Pacific Islander children had significantly higher rate of postoperative hemorrhage/hematoma
African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates of postoperative respiratory failure and physiologic/metabolic derangement
Key Findings: Disparities in Postoperative Adverse Medical Events
Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented that, compared with white children, African-American children had higher risk of
decubitus ulcers, infection following infusion, injection, transfusion, postoperative physiologic and metabolic derangements, and thromboembolism
Latino children had somewhat higher risk of postoperative septicemia, respiratory failure, and physiologic and metabolic derangements
Racial/Ethnic Differences in Perceived Error Severity & Reporting
Survey of 499 parents in an ED revealed racial/ethnicdifferences in parental perceptions of medical error severityand parental preferences for reporting medical errors to adisciplinary body. Compared with white parents, African-American parents significantly more likely to rate 4
medical error scenarios as more severe (62% vs. 49%, respectively; P < .01)
African-American parents significantly more likely to want party responsible for medical error to be reported to disciplinary organizations (50% vs. 33%; P < .01)
Difference persisted even after adjustment for relevant covariates (relative risk, 1.29; 95% CI,1.02-1.58).
Language Barriers and Higher Risk of Adverse Events
Case-control study of 572 children hospitalized at achildren’s hospital documented disparities in risk ofadverse medical events for children whose familiesrequested Spanish interpreters Patients and families requesting Spanish
interpreters had more than twice the odds of serious medical events (odds ratio, 2.26; 95% CI, 1.06-4.81) compared with thosenot requesting interpreters
Unanswered Questions: Disparities and Patient Safety
Many unanswered questions remain about racial/ethnic disparities in pediatric patient safety
More research needed on racial/ethnic disparities in birth trauma and reasons for disparities
Greater insight needed about minorities’ greater risk for infections due to medical care and for postoperative bleeding, sepsis, respiratory failure, and physiologic/metabolic derangement
Not enough known about racial/ethnic disparities in pediatric patient safety in outpatient setting
Unanswered Questions: Disparities and Patient Safety
More research needed on association of language barriers with medical errors and adverse medical events
When medical errors and adverse medical events occur, need to know more about minorities’ perceptions and preferences regarding severity, disclosure, reporting, disciplinary response, and legal action
New Conceptual Model: Racial/ Ethnic Disparities in Patient SafetyNew conceptual model proposed to provide more comprehensive,patient- and family-centered framework for understandingdisparities in patient safety. Five components of model include: Higher prevalence of known risk factors for medical errors in
minorities Medical errors of omission and deviations from optimal practice
frequent and particularly important for minorities Adverse medical event definitions often fail to include important
minority patient views on what constitutes harm Language barriers result in higher risk of medical errors and adverse
medical events Data collection systems for identifying and monitoring disparities in
patient safety often insufficient or absent
Higher Prevalence of Risk Factors for Medical Errors in Minorities1st component of model posits minority children at higherrisk for patient safety disparities due to high prevalence ofknown risk factors for medical errors in minority children Youngest hospitalized children (0-1 year olds) consistently and
significantly more likely to experience patient safety events and youngest children (0-3 years old) at greatest risk for outpatient medication errors
Minorities comprise substantially larger proportion of youngest children (0-5 years old) in US than in general US population: 43% of 20 million 0-5 year olds non-white, compared with 32% of US population of all ages
Thus, youngest US children both more likely to be minorities and to be at greater risk for medical errors and adverse medical events
Higher Prevalence of Risk Factors for Medical Errors in Minorities
Neonates in the Neonatal Intensive Care Unit (NICU) experience highest rates of medication errors and potential adverse drug events of any age group of hospitalized children, and at rates exceeding those of general adult population
African-Americans continue to have substantially higher rates of premature, low birth weight, and very low birth weight infants, accounting for their disproportionate representation among NICU admissions (> ½ of NICU admissions African-American)
Thus, African-American infants at high risk for medication errors and potential adverse drug events because of disproportionately greater risk of NICU admission
Higher Prevalence of Risk Factors for Medical Errors in Minorities
Receiving care in ED has been shown to be associated with higher risk of adverse medical events
Multiple studies document that minority children make significantly more ED visits than white children
Importance of Errors of Omission & Deviation from Optimal Practice
Recent work has called attention to importance of medical errors of omission, in which receiving too little treatment (under-use) results in inappropriate increased risk of disease-related adverse medical events
One study found omission errors accounted for 96% of all medical errors
Most common categories of omission errors include obtaining insufficient information from histories and physicals, inadequacies in diagnostic testing, and patients not receiving needed medications
We propose that medical errors of omission a frequent and important patient safety issue for racial/ethnic minority children, in comparison with white children
Importance of Errors of Omission & Deviation from Optimal Practice
Multiple studies document medical errors of omission among minority children and sometimes serious adverse medical events they cause
Language barriers documented to frequently result in insufficient information from histories and physicals for Latino pediatric patients, including
Omission of important information about drug allergies, past medical history, and chief complaint
Critical distortions in psychiatric symptoms Misinterpretations resulting in quadriplegia and inappropriate
placement of children in social services custody for erroneous diagnosis of child abuse
Importance of Errors of Omission & Deviation from Optimal Practice
Example of inadequacies in diagnostic testing: study of children presenting to children’s hospital ED which found Latino children significantly less likely than white children to undergo two or more diagnostic tests or to have x-rays done
Several studies both in US and UK document substantial racial/ethnic disparities in pediatric asthma treatment, such as significantly lower odds of minorities receiving β2 agonists and anti-inflammatory medications
Importance of Errors of Omission & Deviation from Optimal Practice
Stark example of medical errors of omission: study of white psychotherapists in which 2 case histories presented that were identical except for race of adolescent boy (white vs. African-American)
Compared with white adolescent’s case, psychotherapists gave significantly lower ratings for African-American adolescent for clinical significance of 8 of 21 pathological behaviors
White therapists less distressed about African-American adolescent beating his girlfriend, stealing cars, mistrusting interviewer, and hating his mother
Supports hypothesis that mental disorders in African-American adolescents under-diagnosed because their pathological behaviors rated less severely
Importance of Errors of Omission & Deviation from Optimal Practice
Importance of medical errors of omissions in patient safety raises broader conceptual issue: medical error should be defined as any deviation from optimal practice
This critical adjustment in definition of medical error allows powerful systems approach to error prevention in which an error viewed as a system failure that requires system adjustment
Including deviation from optimal practice as a medical error also underscores crucial interrelationship of patient safety, quality of care, and racial/ethnic disparities
Importance of Errors of Omission & Deviation from Optimal Practice
Deviation from optimal practice associated with higher risk of serious adverse medical events for minorities and may contribute substantially to disparities
Study of over 74,000 very low-birth-weight (VLBW) infants in Vermont Oxford Network revealed minority-serving hospitals (those with >35% African-American infants) had significantly higher adjusted infant mortality rates for both African-American and white infants, vs. hospitals serving <15% of African-American infants
Study of 51 New York hospitals documented hospitals with >80% minority discharges had double adjusted odds of adverse events due to negligence (injuries due to interventions that were inappropriate or did not meet standard of care), compared with hospitals with lower proportions of minority discharges
Patient Safety Definitions Often Fail to Include Minority Views on What Harm Is
Research reveals definitions of medical errors and adverse medical events often fail to capture what constitutes harm and error from perspectives of minority patients and families
Qualitative study of white and African-American patients about preventable incidents resulting in perceived harm in primary care and primary care of their children revealed 70% of harms psychological
For African-Americans, among most important incidents: those in which racism or prejudice occurred
Findings suggest patients and families view breakdowns in patient-physician relationship as more prominent medical errors than technical errors in diagnosis and treatment
Failure to accommodate this patient-oriented definition of medical error and harm, particularly regarding perceived bias/prejudice towards minority patients, could lead to ongoing but undetected disparities in patient safety
Language Barriers & Higher Risk of Errors & Adverse Events
Evidence documents language barriers resultin higher risk of medical errors andadverse medical events
Study of pediatric encounters with LEP Latino children and their families revealed 63% of all errors by medical interpreters had potential or actual clinical consequences, with mean of 19 such errors per encounter
Errors committed by ad hoc interpreters (family members and friends) significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters(77% vs. 53%; P <.0001)
Language Barriers & Higher Risk of Errors & Adverse Events
Errors of clinical consequence in this study included Omitting questions about drug allergies Omitting instructions on dose, frequency, and
duration of antibiotics and rehydration fluids Adding that hydrocortisone cream must be applied to
entire body, instead of solely to a facial rash Instructing a mother not to answer personal
questions Omitting that a child already swabbed for a stool
culture Instructing a mother to put amoxicillin in both ears
for treatment of otitis media
Language Barriers & Higher Risk of Errors & Adverse Events
Study of over 4,000 children seen in ED showed that,compared with English-proficient patients, LEP patientswho had either no interpreter or non-medical, ad hocinterpreters, had: Significantly higher incidence of having medical tests
done (OR, 1.5; 95% CI, 1.04-2.2) Higher test costs (mean difference = $5.73) Significantly greater likelihood of hospitalization
(OR, 2.6; 95% CI, 1.4-4.5) Significantly greater likelihood of receiving
intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3)
Insufficient Data Collection Systems and Patient Safety Disparities
Disparities in patient safety cannot be identified and monitored if data collection systems fail to or inaccurately record patients’ race/ethnicity, primary language spoken at home, and English proficiency
Recent study revealed only 78% of US hospitals systematically collect data on race/ethnicity of patients and only 39% collect data on patients’ primary language
Just 27% of 1,000 hospitals surveyed, however, responded, so these proportions actually may be substantially lower
51% of hospitals collecting race/ethnicity data reported that admitting clerks determined patients’ race/ethnicity based on observation, a method which
Can result in high rates of inaccuracies, missing data, and classifications in “unknown” and “other” categories
Contradicts expert recommendations that such data be collected by patient self-report
Insufficient Data Collection Systems and Patient Safety Disparities
Another recent survey of 500 US hospitals found that 78% collect patient race information, 50% collect patient ethnicity information, and 50% collect primary language information
Although recording language information highly variable across hospitals and rarely a required field
Survey non-response rate was 55%, so, as with aforementioned survey, these proportions actually may be substantially lower
Insufficient Data Collection Systems and Patient Safety Disparities
These findings indicate that at least 22-50% of US hospitals collect no patient race/ethnicity data and 50-61% collect no primary language data
Unclear whether any hospitals routinely collect data on patients’ English proficiency, a measure that has been shown to be more useful for examining health outcomes
Such insufficiencies and absences in collection of data on race/ethnicity and language can result in failure to identify important patient safety disparities
Two Illustrative Examples: Asthma and Language Barriers
Pediatric asthma and language barrierstwo of clearest and most well researched examples of disparities inpediatric patient safety
Next few slides examine patient safety issues associated with asthma andlanguage barriers, using prior patient safety work and definitions as well ascomponents of proposed conceptual model
Pediatric Asthma and Patient Safety Disparities in pediatric asthma underscore important patient safety
issues and conceptual model components that may perpetuate patient safety disparities
Studies document high prevalence of certain risk factors for medical errors among minority children with asthma
Puerto Rican and African-American children experience greater asthma severity and complexity
Asthmatic children from both groups have significantly higher adjusted odds than white asthmatic children of suffering asthma attack in past year and experiencing more severe wheezing
African-American children substantially more likely than white children to be hospitalized for and die from asthma
Pediatric Asthma and Patient Safety Greater ED use another risk factor for medical errors
Several studies document African-American and Latino children significantly more likely to make asthma ED visits than white children
Substantial literature documents frequent errors of omission and deviation from optimal care for minority children with asthma. Studies demonstrate minority children with asthma significantly less likely than white children with asthma to receive prescriptions for
2 agonists Anti-inflammatory medications Medications and nebulizers for home use after hospital
discharge
Pediatric Asthma and Patient Safety Studies also document minority children with asthma subject to
medical errors of commission, exposing them to inappropriate increased risk of iatrogenic adverse events from receiving too much or hazardous treatment (i.e., overuse or misuse errors)
Among asthmatic children in UK, Afro-Caribbean asthmatic children had 8 times the odds and Indian subcontinent children 4 times the odds of asthmatic white children of receiving contraindicated antitussive prescriptions
African-American children with asthma in Washington state Medicaid system found to have significantly higher adjusted odds than white asthmatic children of receiving theophylline prescriptions, which likely is misuse error representing deviation from optimal therapy
Good News: Where There’s Cultural Competency, There’s High Quality
Recent study of 1,663 asthmatic children in 5 health plans in 3 states found practice sites with highest cultural competency scores have
Significantly lower patient under-use of preventive asthma medications(adjusted odds ratio of under-use = 0.15; 95% CI, 0.1-0.4)
Significantly better parent ratings ofquality of asthma care
(Lieu et al. Pediatr. 2004;114:e102-10)
Language Barriers and Patient Safety
Multiple studies document frequently serious medical errors and adverse events that can occur due to language barriers for limited English proficient (LEP) patients and their families who fail to get trained medical interpreter services
Those who need but don’t get interpreters have poor self-reported understanding of diagnosis and treatment plan and frequently wish healthcare providers explained things better
Ad hoc interpreters (family members, friends, untrained bilingual staff, and strangers from waiting room or street)
Misinterpret or omit up to ½ of all physicians’ questions More likely to commit errors with potential or actual clinical
consequences Have higher risk of not mentioning
medication side effects Ignore embarrassing issues when children interpret
Language Barriers and Patient Safety
Interpreter errors in mental health care
shown to result in Overemphasis of psychotic features Under-emphasis of affective components Underestimation of suicide risk Distortions of intellectual abilities, mental status, and
thought disorders Difficulty assessing ambivalent patient attitudes “Normalization” of pathological symptoms
Language Barriers and Patient Safety
Latino parents report lack of medical staff who speak Spanish resulted in poor medical care for 8% of children, misdiagnosis for 6% of children, inappropriate medications for 5%, and inappropriate hospitalizations for 1%
Children whose families request Spanish interpreters have more than double the odds of serious medical events compared with those not requesting interpreter
Study of pediatric ED visits demonstrated that, compared with English-proficient patients, LEP patients who had either no interpreter or non-medical, ad hoc interpreters had significantly higher incidence of having medical tests done, higher test costs, and significantly greater likelihood of hospitalization and receiving intravenous hydration
Language Barriers and Patient Safety
Multiple published case reports dramatically illustrate adverse medical events that can occur when language barriers present
Six-week-old infant admitted for an overdose of barbiturates due to a tenfold medication dosing error by an LEP mother who did not understand outpatient dosing instructions available only in English
Lack of medical interpreter resulted in delayed diagnosis of appendicitis that ultimately evolved into ruptured appendix, peritonitis, wound site infections, and 30-day hospital stay
Language Barriers and Patient Safety
2-year-old girl who sustained fractured clavicle by falling off her tricycle misdiagnosed as victim of child abuse due to misinterpretation of 2 words (“se pegó,” which can mean “she hit herself” or “she was hit”)
Girl and her sibling inappropriately subsequently placed in social services custody after LEP mother was asked to sign over voluntary custody using form only available in English
Misinterpretation of single word (“intoxicado”) by paramedics and ED staff resulted in comatose teen incorrectly being treated and admitted for 48 hours for drug overdose
Subsequently found to have ruptured cerebral artery, resulting in quadriplegia and $71 million legal settlement
Language Barriers andPatient Safety: Case
10-month-old girl taken to pediatrician’s office by her monolingual Spanish-speaking parents and infant diagnosed with iron-deficiency anemia. Pediatrician wrote following prescription in English:
Fer-In-Sol iron drops, 15 mg per 0.6 ml, 1.2 ml daily (3.5 mg/kg)
Parents took prescription to pharmacy. With no available interpreter, pharmacist attempted to demonstrate proper dosing and parents nodded in understanding. Prescription label on bottle written in English
Language Barriers and Patient Safety: Case
Parents administered medication at home and, within 15 minutes, 10-month-old vomited twice and appeared ill
Parents took her to nearest ED, where serum iron level 1 hour after ingestion = 365 mcg/dL (therapeutic levels: 60-180 mcg/dL)
Upon questioning, parents stated they had administered household tablespoon of medication, approximately 15 ml or 43 mg/kg (a 12.5-fold overdose)
Recent Research: Language Barriers, Prescriptions, and Pharmacies
Recent study of pharmacies in major metropolitan area
revealed 47% of pharmacies never/only sometimes can print non-
English-language prescription labels 54% never/only sometimes can prepare
non-English-language information packets 64% never/only sometimes can orally communicate
in non-English-languages 11% use patient family members/friends to interpret Only 55% satisfied with their
LEP patient communication
Conclusions Number of racial/ethnic minority children will exceed
number of non-Latino white children in US by 2030 But very little known about racial/ethnic disparities
in patient safety, particularly in children Review of medical literature revealed several
racial/ethnic disparities in pediatric patient safety, including Higher rates of newborn birth trauma Infections due to medical care Postoperative adverse medical events Greater likelihood of adverse events for hospitalized
children whose parents requested Spanish interpreter
Conclusions Proposed new conceptual model for understanding
racial/ethnic disparities in patient safety includes 5 components Higher prevalence of risk factors for medical errors Frequent medical errors of omission Adverse medical event definitions that often fail to
incorporate minority views on what constitutes harm Language barriers cause higher risk of errors and
adverse events Insufficient data collection systems for identifying and
monitoring racial/ethnic disparities
Implications/Take-Away Points Need to identify and study means of reducing
greater minority risk of birth trauma Need to be especially vigilant regarding
prevention, identification, and management of postoperative infectious and non-infectious complications among minorities
Given many adverse patient consequences of language barriers, appropriate language services always should be arranged for LEP patients and families
Implications/Take-Away Points
Evidence suggests that improving patient safety
for minority children could be achieved by Routinely collecting and monitoring parental self-
reported data on race/ethnicity, language, and English proficiency
Enhancing cultural competency of healthcare providers and staff
Providing adequate language services for all LEP patients and their families