Improving patient safety system implementation for patients with limited English proficiency

Nearly 42 million people speak a language other than English at home, of whom approximately half have limited English proficiency (LEP). Research suggests that among persons who experienced adverse events, LEP patients are more likely to be harmed, and the harm is more likely to be serious.

The Agency for Healthcare Research and Quality aims to improve the safety of LEP patients by developing a new TeamSTEPPS training module and hospital guide. TeamSTEPPS is a system to improve the quality, safety and efficiency of health care by improving communication and teamwork skills among health care professionals. The Module will show how team-based patient safety approaches can be adapted to meet the needs of linguistically and culturally diverse patients, bringing culturally and linguistically appropriate services into the mainstream patient safety effort. The Hospital Guide will provide information to help quality and safety leaders implement systems to identify, report, prevent and address medical errors caused by language barriers.

To inform the development of the Training Module and Hospital Guide, Abt Associates and the MGH Disparities Solutions Center conducted a mixed methods study to identify where LEP patients experience the most medical errors and why, and which team behaviors and hospital policies could prevent these errors. The study included an environmental scan, quantitative analysis of patient safety and interpreter databases, analysis of a pilot interpreter patient safety project, stakeholder interviews, and a Town Hall Meeting. We will share our findings as well as promising tools and techniques based on those findings.