Losing Less in Translation


The emergency department is undoubtedly the area of the hospital that most frequently requires the services of interpreters. As of January 1, 2011, the Joint Commission requires the use of “qualified translators” in the emergency department 24/7.

As of January 1, 2011, the Joint Commission requires the use of “qualified translators” in the emergency department 24/7.
Rick Bukata, MD, reviews the relevant research and offers his translation.


The emergency department is undoubtedly the area of the hospital that most frequently requires the services of interpreters. Most hospitals subscribe to telephone-based interpreter services, but using them, except for the most uncommon languages, can be a hassle in that ED patient encounters not only require communication with the patient when an initial history is obtained, but often times throughout the course of the visit.

There is ongoing communication that is required for a myriad of reasons, from assessing the response to treatment to the progression of symptoms to providing aftercare instructions. Clearly, repetitive calls to telephone-based translation services for these additional communications is not likely to happen and traditionally the ED staff and the patient and/or his/her family generally have made do.

Is this ideal? Certainly not. But, until now, EDs have gotten by.


Have there been some negative consequences regarding inadequate translation? This must be the case. As a matter of fact, a study entitled Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study that was published in the International Journal of Quality in Healthcare in 2007 found that more communication-related adverse events were reported for patients with limited English proficiency than those who spoke English. Other studies note more problems with follow-up care in these cases as well.

One 1980 case that is frequently cited regarding the problems that can occur with inadequate translation involved the case of Willie Ramirez, a Spanish speaking teenager in South Florida who went to an ED and complained of a headache and dizziness. He and his family insisted he was “intoxicado” and this contributed to him being diagnosed as an intentional overdose. Apparently, the word “intoxicado” in Spanish can mean feeling dizzy or nauseous. The bottom line – an intracranial hemorrhage that resulted in quadriplegia was missed and a $71 million dollar settlement resulted. To be fair, to what degree the misdiagnosis hinged on this one word is unclear.

The fact is that a number of states now require “qualified” medical translators and Federal law has long been on the books also mandating qualified translators. More specifically, Title VI of the Civil Rights Act of 1964 prohibits hospitals that receive federal funds from discrimination based on race, color or national origin and includes patients who are not proficient in English. Also the Rehabilitation Act of 1973, which focuses on individuals with disabilities, requires the provision of effective communication for patients who are deaf or hard of hearing, and by extension, those with limited English proficiency.

Now the Joint Commission has stepped up to the plate. As of January 1, 2011 (that’s right – five months ago) the JC requires the use of qualified translators 24/7. Surveyors have been instructed to check for compliance, although hospitals cannot be officially sanctioned until at least January 1, 2012 (at a minimum).


So, hospitals will now be in the business of determining whether those who do translation in their facility are “qualified.” Certainly, they can continue to use the telephone-based services – and most of these services are way ahead of the game in that they require their interpreters to pass tests involving HIPPA, medical terminology, anatomy and are required to interpret word for word.

However, it is not practical to use the telephone-based services for languages that are common, such as Spanish. In this case, the hospitals will need to get into the translator-qualifying business, or hire “certified” translators. And yes, now there now are “certified” medical translators.

In 2009, the National Board of Certification for Medical Interpreters established the National Medical Interpreter Certification and, in addition, the Certification Commission for Healthcare Interpreters has a certification program. Both require the passage of oral and written exams encompassing the same elements noted above by the telephone-based companies (who were actively involved in establishing criteria for certification). As anticipated, the Bureau of Labor Statistics has predicted a huge increase in the need for qualified medical interpreters.

The next question. Who pays for this unfunded mandate? Medicare doesn’t. Medicaid can if states elect to provide this payment (and it is matched with Federal funds) – but, as anticipated, most states have elected not to pay. And, as noted above, some states require the use of qualified interpreters but they, too, do not pay.

Even in states that mandate the use of qualified translators their use is limited. As an example, a study titled Reevaluation of the Effect of Mandatory Interpreter Legislation on Use of Professional Interpreters for ED Patients with Language Barriers in the journal, Patient Education and Counseling, demonstrated that despite Massachusetts’s 2001 law, there was no substantive increase in the use of qualified interpreters in four Boston EDs surveyed (from 15% in 2002 to 18% in 2008). It should be noted that over the time period studied, the use of friends or family members as translators increased substantially and it was noted that the majority of patients were comfortable with these people acting as translators. The issues with use of family or friends is largely the quality of the translation and potential privacy issues – and the use of children as translators is considered even more potentially problematic.

So, its time to break the news to your CEO. Be sure to remind him/her that you are only the messenger. And hopefully the JC will start taking on other issues that could meaningfully help the ED – like some regulations regarding waiting times and the holding of admitted patients.



  1. Or we could treat the problem and not the symptom- make English the official Language of the US.
    No other country in the world demands that the hospitals supply translators for all. And of course, this is all unfunded. Your translator line can cost you more than what you get reimbursed for seeing the patient.
    It’s about time we started saying “No” to the government.
    Or how about “Nyet, Nein, Non, etc…”

  2. Thank you for presenting this issue directly to physicians, who are often the ones with the power to decide to call an interpreter or not. As you pointed out, there are many disadvantages of using family and friends as interpreters, among them bias and lack of confidentiality, accuracy, terminology and ethical protocols, and many more. An impartial, trained, professional interpreter, whether she is used face-to-face or over the phone, is always better.
    It also costs less than a lawsuit, which is what happens if Title VI is violated.
    Most importantly, using a qualified interpreter will greatly enhance communication and therefore patient safety and public health, which is what we all want.

    (full disclosure: I am the Chair of the National Board of Certification for Medical Interpreters)

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