Risk Management for Healthcare Interpreters
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The document presents case studies highlighting failures in healthcare risk management related to language barriers, particularly for Spanish-speaking patients. In the first case, a patient underwent surgery to remove the wrong kidney due to inadequate communication and the improper use of family members as interpreters. The second case discusses the negligent death of an infant because emergency room staff failed to gather a complete medical history from the patient's Spanish-speaking parents, further exacerbated by the absence of a qualified interpreter.
Risk Management for Healthcare Interpreters
- 1. 際際滷 Handouts for Risk Management for Healthcare Interpreters These slides are meant for reading, rather than presenting
- 2. Barbara Lightizer, MS, MA, CPHRM Director Risk Management, Patient Relations & Interpreter Services NEWTON-WELLESLEY HOSPITAL Greg Figaro President & CEO
- 3. Risk Management The process of making and carrying out decisions that will help prevent adverse consequences and minimize the negative effects of accidental losses on an individual or an organization.
- 4. Case Studies ! Case 1: Investigation of Surgical Procedure Leading to Removal of Wrong Kidney on Spanish Speaking Patient ! Case 2: Death of Infant Patient with Apnea After Repeated ER Visits and ERs Failure to Obtain Complete History from Spanish Speaking Parents
- 5. Case 1: Wrong Kidney Removed A States Department of Public Healths Investigation of Surgical Procedure Leading to Removal of Wrong Kidney on Spanish Speaking Patient
- 6. Case 1: Wrong Kidney Removed Male patient scheduled for kidney removal Case Patient with comorbidities, high risk Overview Speaker of Spanish Outcome: removal of the wrong kidney!
- 7. Case 1: Wrong Kidney Removed Son didnt know which kidney was to be removed Site Marking with Patient Son translated surgical consent form for father Involvement and assumed the document was correct Patient Patients care plan said to use interpreter to interviews explain the plan of care conducted with the No evidence that a Spanish-speaking provider explained plan of care to patient patients son interpreting Surgeon reported patient may not have known which kidney was to be removed
- 8. Case 1: Wrong Kidney Removed The hospital failed to provide the patient with several standard safeguards and rights: Investigation " Clinical Privileges Findings " Universal Protocol: Prevention of Wrong Patient, Wrong Procedure, Wrong Site Surgery/Procedure " Right to receive information in patients primary language
- 9. Case 1: Wrong Kidney Removed The facilitys failure to implement policies and procedures for Medical Staff led to the removal of the incorrect kidney of Patient. Further, it led to Investigation Patients mistakenly signing a consent Findings for removal of the incorrect kidney. This is a deficiency that has caused a serious injury or death to the patient, and therefore constitutes immediate jeopardy within the meaning of the Health and Safety Code
- 10. Case 1: Wrong Kidney Removed Before surgery, they marked the right side. I Patients Sons Perspective didnt have a clue what side they told me they found a tumor on the kidney
- 11. Case 1: Wrong Kidney Removed I translated the document (the surgical Patients Sons consent) for him Perspective (Patient). I didnt know if the right or left side was correct. I assumed it was correct.
- 12. Case 1: Wrong Kidney Removed Order and consent verified with Patient, x-rays, other Data. was circled Yes. The section Clinical which indicated surgical site/ Perspective side verification, was reviewed. The section which indicated Site/Side confirmed with patient, surgeon, was blank. The Side was circled, Right.
- 13. Case 1: Wrong Kidney Removed An interview conducted with Surgeon on July 16, 2009 Surgeon stated. The patient may not have fully understood which kidney Clinical There was no documented evidence Perspective that patient was provided information about his diseased left kidney, options, use of anesthesia, of possible risks and complications by staff member. There was no documentation found to indicate a Spanish speaking clinician reviewed the consent Patient signed
- 14. Case 1: Wrong Kidney Removed Lack of use of a qualified interpreter Use of family member to interpret consent forms and to verify site/side Risk to be operated on Management Perspective Inadequate time-out the meeting between the surgical team and the patient Inadequate documentation
- 15. Case 2: Death of Infant with Apnea Hospital Found Negligent in the Death of Infant Patient with Apnea After Repeated Visits to Emergency Room and Failure to Obtain Complete History from Spanish Speaking Parents
- 16. Case 2: Death of Infant with Apnea Eleven-day-old female infant patient with a history of apnea The patient stopped breathing while at home, was revived by family, and brought to the ER Case This is a Spanish-speaking family and the firefighter Overview noted the language difficulty The hospital failed to obtain a complete history and failed to give proper discharge instructions to the parents When brought to the ER the next day, the patient was placed in Intensive Care and subsequently died
- 17. Case 2: Death of Infant with Apnea At the hospital emergency room, a triage nurse evaluated the patient without an interpreter Other providers took history from the patients uncle, who used broken English and gestures; no interpreter was present Clinical No mention has been made that the patient had Sequence stopped breathing or been revived by her uncle A Spanish-speaking doctor later took history from patients mother, ran blood tests, found no bleeding disorders Patient released, family given handwritten instructions mostly in English on conditions necessitating return
- 18. Case 2: Death of Infant with Apnea The next day, Patient stopped breathing again; father revived her and she was Clinical brought back to the hospital Sequence (Continued) Hospital interpreter was present this time The patient was placed in intensive care and Next day: died as a result of oxygen deprivation due to Patient undiagnosed lung infection Returns to Patient was removed from life support Hospital systems after four days Autopsy showed patient had lung infection that likely caused apnea
- 19. Case 2: Death of Infant with Apnea Failure to use a professional interpreter to take initial history Multiple consequences as a result of the failure to use a qualified interpreter Risk In a wrongful death case, a court found Management the plaintiffs negligent, including: Perspective " Should have made a more careful assessment of the patient " Failure to diagnose her condition influenced by the lack of adequate communication