Lidia Schapira1, Joseph R. Betancourt2, and Alexander R. Green2
1 Division of Hematology and Oncology, Massachusetts General Hospital, Boston, USA 2The Disparities Solutions Center, Massachusetts General Hospital, Boston, USA KEY POINTS
• Foster a supportive culture to ensure the safety of diverse patient populations.
• Adapt current systems to identify medical errors among patients with low proficiency in the majority language.
• Improve reporting of medical errors for patients from minority populations.
• Routinely monitor patient safety for patients from ethnic and racial minorities and those who are not proficient in the dominant language.
• Address root causes that result from language discordant encounters.
Introduction and background There is now considerable evidence that health and healthcare experiences vary along ethnic and racial lines and that minority groups are at risk of significant disadvantage. The role of language barriers and their impact on adverse events is receiving greater attention as medical establishments step up their efforts to improve safe practices. In the United States, research has demonstrated that patients who have limited English proficiency (LEP) are more likely to suffer unintended harm from treatment, and regulatory organizations have responded by implementing new standards that emphasize the importance of language, cultural competence, and patient-centered care. Such problems are not limited to the United States. Since migration is increasing worldwide, the number of people who do not speak the dominant language of the country in which they live is similarly increasing.  Immigrants diagnosed with cancer have poorer outcomes than comparable non-immigrant groups, with lower screening and survival rates, more adverse effects, poorer quality of life, and greater distress.  While individual countries must develop operating procedures and protocols to handle the care of ethnic minorities, there is agreement regarding the need to train healthcare professionals to meet these challenges through improved awareness and communication, in addition to strengthening safety practices within medical establishments to minimize harm.
Medical errors and mishaps can involve doses of medications, procedures or laboratory reports. In addition to errors, we must consider the occurrence of adverse events caused by medical care. Examples include pneumothorax from catheter placement prior to chemotherapy, side-effects from anti-cancer medications, or post-operative wound infection. Finally, a near miss or close call is typically an event or situation that did not produce patient injury, but only due to chance. This good fortune might reflect the robustness of the patient (e.g., a patient with a penicillin allergy receives penicillin but has no reaction) or a fortuitous timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart). If we consider errors more broadly, and include also mistakes in judgment, blunders, and gaffes, we confront a more prevalent problem. Common conversations surrounding cancer treatment, such as giving bad news or asking for consent for chemotherapy, require accurate and empathic communication and can easily lead to a misunderstanding when patient and doctor cannot speak directly to one another. In a candid essay, Tattersall reflected on 35 years of practice and lamented the fact that he could remember only those errors that occurred early in his career, leading him to wonder if others went unrecognized.  While surgical errors or medication overdoses are detected immediately, subtle misunderstandings or adverse events may not ever be detected or recognized in a system that is increasingly fragmented, where patients receive treatment by separate teams working in various locations often without direct communication.
In addition to philosophical and ethical imperatives, quality and cost drivers support work in the areas of patient safety that result from language differences. In the United States, 57 million people, 20% of the US population, speak a language other than English at home. Approximately 25 million people, 8.6% of the US population, are defined as LEP.  Since 2000, six of every ten babies born in New York City have at least one foreign-born parent, and US hospitals are increasingly challenged to provide emergency care for undocumented migrants, most of whom now reside in suburban areas.  This migrant population is at high risk for longer hospital stays, greater risk of infections, falls, pressure ulcers,  surgical delays, readmission due to greater difficulty understanding instructions, [6, 7]
and a greater chance of readmission to the hospital when professional interpreters are not used at admission or discharge. In oncology, research has also shown that patients who are less fluent receive less optimal palliative care, are less likely to die at home, more likely to have emotional symptoms, and less likely to receive adequate symptom control.  There is a pressing need for policy initiatives to address these disparities and for initiatives to train the medical workforce to handle a diverse population. In an eloquent essay, Surbone wrote that it is impossible to separate cultural competence in the clinic from broader policy issues and that clinicians have a moral imperative to act on behalf of patients who are most vulnerable. 
Case Study 8.1 The Case of Carmen Hernandez.
Mrs. Hernandez is a 68-year-old woman from Ecuador who was diagnosed with stage IV breast cancer. She initially presented three years earlier and had been treated with curative intent and then relapsed with bone and pulmonary metastases. She moved to the United States 10 years ago when her husband died and she has been living with her son and his family. She speaks a little English - enough to communicate some basic things with her grandkids - but otherwise is primarily Spanish speaking. She has a high school education and reads well in Spanish. She was recently scheduled for a same-day surgical procedure for the insertion of an indwelling catheter to deliver chemotherapy. Her son was present to interpret. The physician, directing his question to her son, ran through her list of medications to check which of them she was currently taking. He focused specifically on a prescription for oxycodone and diazepam that she had been given several months ago, and her son mentioned that she was not taking those.
Mrs. Hernandez underwent the procedure but afterwards she was not arousable. She was taken to the emergency department and later admitted to the hospital where her level of consciousness gradually improved. She had been quite anxious about the procedure and was given a moderate dose of lorazepam to help calm her. It was felt that this dose may have been too much for her. Later when she was more alert, working with a professional interpreter, the care team learned from her directly that she had in fact been taking both diazepam and oxycodone for at least a week prior to the procedure. Rather than recognizing and disclosing that the care team who took her initial medication history had made a mistake by not ascertaining this information directly from her, they placed the blame on Mrs. Hernandez for not being honest about this important information.
This story raises many concerns about the safety of care for patients with limited English proficiency and cultural differences, and also raises ethical questions about the role of the healthcare team in disclosing errors that occur based on factors that they may not even recognize. These are challenging issues to handle even for patients who speak English well. However, when this is complicated further by language barriers and cultural differences, the difficulty is magnified. In this case, the overdose of benzodiazepines mixed with opiates could have been prevented if there was a policy and a system in place of engaging professional interpreters always, especially in high-risk situations like pre-operative assessments and medication reconciliation. This chapter will explore these issues in depth, and will recommend some effective strategies for addressing them.
Errors, language, and culture Recent research by Betancourt and Green has identified three common causes of errors (or potential errors) for LEP and culturally diverse patients: (i) use of family members, friends, or nonqualified staff as interpreters; (ii) clinician use of basic language skills to "get by," and (iii) cultural beliefs and traditions that affect care delivery. 
Use of family members, friends, or nonqualified staff as interpreters Family members and friends may not understand the subtle nuances of language and culture used by the physician and may not question the use of medical terminology that they and the patient do not understand. Furthermore, issues of confidentiality may prevent patients from disclosing critical health information. There is a paucity of data regarding the influence of a partner, guest or companion in the medical encounter in general, even in language concordant encounters.  Most cancer patients are accompanied by a relative to their initial consultation and subsequent visits, and this companion may assume an active role in decision-making. If this relative also assumes the role of de facto interpreter and has little medical knowledge, the patient may be misinformed. Relatives will seek to protect the patient and may editorialize or change the message conveyed by the physician. Professional interpreters, on the other hand, are trained to play a critical role in clarifying, advocating, and acting as cultural brokers, thus reducing the likelihood of misunderstanding or error. Butow and colleagues in Australia analyzed audiotapes of oncology consultations mediated by both ad hoc and professional interpreters.  They identified multiple types of errors, where information was either omitted or corrected or editorialized, the message was simplified in order to reduce the emotional impact on the patient, the interpreter introduced more or less certainty than what was conveyed in the original message, used euphemisms, appeared more authoritative or paternalistic than the oncologist, and simply provided misinformation. These errors occurred more frequently when family or ad hoc interpreters translated than when professional interpreters were involved. 
Professional interpreters act as cultural brokers by helping clinicians to understand the patients' cultural beliefs and practices, as well as helping the patients in understanding the dominant culture. Interpreters can interrupt the clinician and ask for a clarification and thus prevent costly and critical errors. They can improve team communication by using structured tools (e.g., check-backs), in conjunction with the care team, to ensure patient comprehension. International standards of practice for medical interpreters were first adopted in 1995 and are organized into three major areas: interpretation, cultural interface, and ethical behavior.  Patients receiving their care in community practices may experience additional difficulties in access to trained interpreters. For hospital-based oncology teams, access to professional interpreters is generally easier, although it often requires advanced planning. Challenges remain in ensuring that interpreters working with cancer patients have sufficient knowledge of terms that are typically used to explain the biology, stage, and treatment recommendations. Interpreters have reflected on the difficulties and frustrations they experience when patients and families have different or unrealistic expectations, especially when relatives include them in collusion about non-disclosure of information or when they feel excluded from participating in discussions with the treatment team. [1, 13, 14]
Clinician use of basic language skills to get by"
Research confirms that untrained hospital staff also serve as interpreters for LEP patients, despite evidence that hospital staff who serve as interpreters on an ad hoc basis are more likely to make clinically significant mistakes than qualified medical interpreters. [15, 16] Clinicians with basic or intermediate foreign language skills often attempt to "make do" or "get by" without the use of a competent interpreter, often with serious consequences. [15, 17] They may be unaware of nuances in spoken language or dialect and incorrectly assume that their medical message was properly understood. They may rely on nonverbal communication, such as nodding or smiling, and may have an empathic demeanor but fail to provide accurate information. Physicians in hospital clinics may avoid using interpreters simply due to time pressures, whereas those in community practices may have limited access to trained interpreters and may need advance planning. In the United States, hospitals are required by federal law to offer professional interpretation services to patients with low English proficiency, but the government provides no reimbursement for this service.
Cultural beliefs and traditions that affect care delivery Professional interpreters also assist clinicians in deciphering cultural traditions and beliefs that influence the reporting of symptoms such as pain, or explain a patient's passivity in the context of a critical situation. Deferring to authority figures may be the cultural norm for some patients with cancer and is often misunderstood by Western trained physicians who are increasingly accustomed to vocal patients demanding information and equal roles in medical decision-making. Confronted with a patient who appears reluctant to voice opinions, clinicians may feel disconcerted and need guidance. Some clinicians harbor deeply held opinions about the responsibility of immigrants to learn the dominant language and often express indignation or surprise when a patient who resides in their adopted country for many years shows no sign of understanding the dominant language. There are many reasons for such inability to master a second or third language, ranging from lack of access to classes, advanced age, poor literacy in the primary language or difficulty understanding instruction. Moreover, learning the language may not be sufficient to follow a detailed medical conversation, especially when one is very anxious or has received a sedative medication for a surgical procedure.
Cross-cultural communication and bias Efforts to improve safety need to address procedural and communication errors that can lead to suboptimal care. Surgical and clinical decisions are influenced by physicians' stereotypes and biases that remain unrecognized and under reported or simply missed. Santry warned colleagues that such biases present a great risk to surgical safety by interfering with surgeons' judgment and clinical decisions.  SEER data have repeatedly shown that in surgically treatable cancers, such as low-grade gliomas and other brain tumors, squamous cell cancer and adenocarcinoma of the esophagus, and non-small cell lung cancers, blacks have lower rates of surgery compared with whites even when disease stage is equivalent. [19-24] These disparities in treatment have also been seen in referral for adjuvant therapy. Blacks with rectal cancer were less likely to receive adjuvant chemotherapy or undergo a sphincter-sparing procedure. [25, 26] For patients with locoregional pancreatic adenocarcinoma, blacks were less likely than whites to be referred to a medical, radiation, or surgical oncologist and, even after referral, they were still less likely to be treated with chemotherapy or surgical resection.  Gender disparities have been shown in non-small cell lung cancer patients, where women were less likely than men to be treated with chemotherapy even when controlling for rates of oncologic referral.  These SEER data may not explicitly reveal the effect of unconscious bias on these cancer disparities, but they alert us that race, gender, and ethnicity play an important role in types of treatment offered or rendered for cancer treatment.
Racial and ethnic disparities in physician-patient communication appear to be a global phenomenon. A Dutch study reported lower levels of positive affect among both patients and physicians during the visits of racial/ethnic minority patients compared with the visits of native-born Dutch patients.  An audiotape study of primary care practices by researchers at Johns Hopkins in the United States showed physicians were more verbally dominant, displayed less affect, and tended to be less patient centered in their approach with black patients than with white patients.  These authors concluded that patient engagement and participation, rather than overall time spent during medical visits, may contribute to health disparities. Varying levels of trust in physicians and medical establishments have also been hypothesized to contribute to racial disparities.  Gordon reported that black patients had significantly lower levels of trust following an oncology consultation for lung cancer than white patients at a VA Hospital.
 Black patients perceived their physician as less supportive, less partnering, and less informative than white patients.  These findings are consistent with research reporting that black patients had less positive experiences of communication and that physicians engaged in less active decision-making. Trust in physicians is indispensable for crafting a solid therapeutic relationship and directly affects the likelihood that a patient will follow complex directives or adhere to a medical treatment such as chemotherapy, typically unpleasant and accompanied by side-effects that impair quality of life. Physicians and patients may underestimate one another's sense of engagement during medical encounters by misinterpreting one another's non-verbal behaviors, a communication error that may strain the therapeutic alliance.
Error disclosure There is a paucity of data about the mechanisms clinicians use to communicate errors in language or culturally discordant situations. We can infer from the literature on cross-cultural communication that the actual disclosure may also be subject to miscommunication and that information may be avoided, minimized or distorted either intentionally or unintentionally. In the United States and other developed nations, there has been a significant shift in communication practices that now routinely favor transparency, candor, and full disclosure of adverse events.  Effective disclosure is a multistep process that involves several discussions with the patient that should go beyond mere words; it should also include actions taken by institutions to prevent similar errors.  Some hospitals have trained disclosure coaches to assist clinicians and teams through this process. These coaches encourage patients and families to become involved in the event analysis process, searching for root causes and implementing changes to prevent such errors from happening in the future. 
The gravity and urgency of the mistake determines the response. After noting a chemotherapy overdose, the senior oncologist on the treatment team needs to notify the patient and family and take all the appropriate measures to mitigate the harm. Verbal and written apologies are indispensable and typically offered by the most senior member of the team; although in certain situations, the patient may prefer to hear directly from the person who made the mistake. In the case of our chemotherapy over- or mis-dose, the error could be caused by the chemotherapy ordering system, the pharmacist who prepared the medication, the nurses who administered the therapy, or perhaps the entire team who implemented the wrong order. The apology serves an important purpose, and needs to be accompanied by an explanation and acknowledgment of error in language the patient is able to understand. In the setting of cross-cultural practice, the best advice we can offer clinicians is to avoid making assumptions about what the patient knows or wants to know and to consider the degree of distress and tailor the information accordingly. Youngston reflected that "errors may constitute the end of a sequence of events which may involve many 'contributors.'" In the case of language barriers, it is essential to ask for assistance from a trained interpreter and to give him or her advanced notice of the anticipated content of the meeting.
Five strategies to reduce errors We offer five key strategies to prevent or reduce errors and address disparities in cancer prevention, diagnosis, and treatment.
Foster a supportive culture to ensure the safety of diverse patient populations Individual clinicians play a major role but cannot effectively transform an institutional culture without support at the leadership level. We suggest that hospital clinics or medical offices integrate the message of overcoming cultural and language barriers into their mission statement. Crafting an institutional culture that is sensitive to the needs of vulnerable populations requires a concerted effort and multiple iterations and negotiations, where professionals have opportunities for ongoing training activities that address cultural sensitivity.
Recognizing that patients who are not fluent in the majority language are at risk for adverse outcomes is an important first step in fostering a culture of safety and ought to be part of the basic training provided to all employees. Improving signage in hospital corridors, having multilingual staff that is friendly and welcoming, and involving community leaders and patient navigators in advisory boards are simple steps that can help shape the institutional message. Clinicians need opportunities to learn how best to interact with professional interpreters since many were never trained and thus improvise without method or strategy. Likewise, interpreters need opportunities to develop their professional skills and to learn the specific concepts and idioms required to participate in encounters dealing with cancer treatments. Donelan surveyed interpreters from several Boston hospitals and showed that they did not have sufficient command of terms routinely used by oncologists and that their knowledge improved after a short training intervention. 
At Massachusetts General Hospital, in addition to having trained medical interpreters, each inpatient care unit houses a mobile interpreter phone, which can be rolled into any patient's room and hooked up to a wall jack to provide telephonic interpretation on demand in any language. Some hospitals provide patients with an "interpreter requested card" in their language and in English that can be used throughout the care process to notify clinicians and other staff that the patient requires an interpreter. This strategy visually reminds staff of the patient's LEP status and helps encourage patients to participate in their care. One hospital described a system that flags previously hospitalized LEP patients at admission and automatically links them to Interpreter Services. The patient is then placed in a queue to be checked on (regardless of whether interpreters conduct rounds to check on LEP patients).
Promoting patient and community engagement through participation in cultural advisory groups can sensitize clinic and hospital administrators to specific issues and concerns of minority groups who report discrimination or disadvantage. By focusing on the patient experience, healthcare professionals can identify practices that require change. Certain cultural or religious groups may request or even demand that the institution consider procedural or structural changes to accommodate patients' religious practices and observance of major holidays. Responding to a request from a senior staff physician, Children's Hospital in Boston installed a Shabbat elevator as a way to circumvent the Jewish law requiring observers to abstain from operating electric switches on the Sabbath. This elevator operates automatically and is marked with a sign noting that it is specially configured for Shabbat observance, stopping at every floor. This allows parents of hospitalized children to visit every day, often carrying babies, without having to climb the stairs to reach top floors. To accommodate the dietary practices of both Muslim and Jewish patients, the Oncology unit at Hadassah Hospital in Jerusalem, Israel, allows families to prepare and store their own meals in a large kitchen that is housed within the cancer ward. These two examples show how responsive institutions adapt to meet the needs of the patients they serve.
Increasingly, patient navigation services are seen as the solution to help patients obtain the best possible care. Navigators are paraprofessionals with varying educational credentials ranging from high school diplomas to advanced nursing or counseling degrees, and are integrated into the care team to help patients understand and obtain the medical services they need. Patient navigators have been shown to reduce disparities along the continuum of cancer related services, from screening to receipt of effective treatment.
Adapt current systems to identify medical errors among patients with low proficiency in the majority language Noting and reporting adverse events is common practice for oncologists. Trainees typically learn to grade adverse events using established manuals and record the severity of such events using standardized scales in routine clinical documentation. Clinical trials depend on the accurate reporting of adverse events and these are in many instances subjective assessments. Research performed over the past decade has demonstrated that patient reported outcomes (PRO) are not only acceptable for documenting adverse events in clinical trials, but also useful in reporting adverse events in clinical practice.  If patients are able to recognize, grade, and report physical symptoms, we can also postulate they could be trusted to report errors and adverse events related to communication or system malfunction. Increasing the involvement of patients in reporting their experiences could also serve to alert the clinical teams of any potential conflict based on faith or tradition.
Improving the data captured in electronic medical records may allow us to monitor and integrate demographic information with safety reports, stratify medical errors and adverse events by race, ethnicity, and language, and identify disparities in patient safety. We also recommend the implementation of policies to guide when a live professional interpreter is required or when a telephonic interpreter or other mechanism will suffice. Ultimately this should improve our ability to spot errors that resulted from faulty systems in need of change. Querying databases to identify reasons for treatment delays or lack of adherence to medication may provide simple answers and point to corrective measures. For example, if a patient missed an appointment for a breast biopsy following an abnormal mammogram, a quick look at the electronic record could show that she was handed written instructions in English stating the time and place of her appointment, without checking first to see if she could speak or read the language.
Improve reporting of medical errors for patients from minority populations The Joint Commission's "Hospitals, Language, and Culture: A Snapshot of the Nation" (HLC) study was designed to gather information about the activities hospitals are undertaking to address cultural and language needs among an increasingly diverse patient population.  Beginning in February 2005, members of the HLC research team recruited a sample of 60 hospitals from 32 states across the country and conducted surveys and site visits.
The HLC study revealed that although 43% of the hospitals identified a direct relationship between patient safety issues and patients' linguistic needs, only one hospital reported stratifying their adverse event data by language. When the link between patient safety, language, and culture was discussed during site visits, only a few hospitals indicated that they were able to quantify this connection. The one hospital that stratified their adverse event data by language found clusters of adverse events in patients with English as a second language. The ability to demonstrate the link between language and safety had sensitized this hospital to the challenges of providing care to LEP patients.
Betancourt and Green identified several key areas in need of improvement to ensure that hospital staff are empowered and can identify and report medical errors that occur among LEP and culturally diverse patients. They recommend creating a hospital-wide public relations campaign about the importance of safety reporting, with a particular focus on the issues that frontline staff and interpreters are concerned about (e.g., being viewed as snitches, losing trust of healthcare professionals, or being alienated from the care team). Frontline staff and interpreters need to be trained to recognize and report any patient safety events they witness, including near misses.
Reporting systems need to be user-friendly, promoting a system of accountable care rather than blameless reporting. They recommend using medical error reporting as a learning tool by experimenting with novel reporting mechanisms such as audio-recordings or focus groups to capture near misses and draw attention to this prevalent problem.
Routinely monitor patient safety for patients from ethnic and racial minorities and those who are not proficient in the dominant language Hospitals do not routinely monitor or analyze medical errors among culturally diverse patients or those with limited language proficiency. We recommend developing routine clinic or hospital-wide safety reports that focus on patient safety for these populations. Linking these efforts to other important clinic or hospital initiatives, such as patient safety or patient experience committees, will help establish a culture of accountability. One hospital analyzed their patient safety report database by keywords, such as language, language barrier, and interpreter, and generated a monitoring report that found assorted mistakes that contributed to the incident being investigated. These included errors in written translations, the use of ad hoc or family members as interpreters, care routinely being provided without an interpreter, and the presence of an interpreter who spoke a different language than what was required. We recommend inserting these topics into the agenda of standard operating conferences such as Morbidity and Mortality Rounds or other multidisciplinary administrative and clinical conferences, in order to draw attention and increase awareness. Identifying trends and piloting corrective interventions can lead to substantial improvements.
Address root causes that result from language discordant encounters Errors can be prevented by addressing their root causes and with targeted prevention strategies. These strategies might include a focus on particular high-risk scenarios that build on a robust patient safety identification, reporting, and monitoring system. We recommend creating teams of trained nurses and social workers to increase and improve the use of interpreters for patients and families who are not fluent in the dominant language. Clinics and hospitals must have access to trained interpreters and integrate them into the multidisciplinary team. Interpreters can conduct regular rounds on inpatient units, checking in on patients, even when clinicians do not call them, as an additional support network. Better coordination of in-person interpreter services in outpatient clinics is indispensable and requires good communication between clinicians, schedulers, and frontline staff.
Cancer patients are routinely given written materials that explain their disease and treatment. Informed consent for treatment involves signing complex forms and consent for treatment on a clinical trial requires that patients be provided lengthy documents to ensure their proper understanding. Such procedures may prove to be overwhelming for patients with low literacy or low language proficiency. In these cases, access to proper treatment then depends entirely on the availability of interpreters as well as the expertise of clinicians in mediating language and cultural barriers and working smoothly and effectively with interpreters.
We recommend establishing a mechanism to schedule an interpreter automatically for patients who need or require such services. We also recommend the implementation of policies to guide when a live professional interpreter is required or when a telephonic interpreter or other mechanism will suffice. When working with the interpreter, we recommend that clinicians plan ahead what they want to say; avoid confusing the interpreter by backing up or rephrasing, speak clearly, make frequent pauses, use short questions, avoid idiomatic expressions, abstractions or metaphors and avoid using jokes or humor that might be offensive or misunderstood. Positioning themselves so they are in direct contact with the patient and can maintain eye contact at all times is important, typically having the interpreter to the side and slightly behind the patient so that he or she does not distract from the important dyadic exchange.
Conclusion The passage of healthcare reform and current efforts in payment reform signal the beginning of a significant transformation of the United States healthcare system. An entirely new set of structures are being developed to facilitate increased access to care that is cost-effective, and of high quality. Pursuing high-value health care is the ultimate goal. Guided by The Institute of Medicine (IOM) Report "Crossing the Quality Chasm," we chart a path to deliver care that is safe, efficient, effective, timely, patient-centered, and equitable.  There is no doubt that significant gains have been made in this effort, particularly in the area of patient safety. [36, 37] However, assuring the safety of patients with the principle of equity in mind, in particular for those with LEP, has garnered significantly less attention, and has yet to be realized. This is despite evidence - not to mention the application of common sense - that LEP patients are disproportionately impacted and more significantly harmed by safety events, especially in communication-sensitive situations. The area of oncology and cancer care is not spared, and remains a prime target for transformation.
The path to achieve safety for LEP patients may not be well worn, but there is certainly a strong, evidence-based roadmap available and at our disposal. Proven quality improvement strategies, that include system-based and team-based initiatives and interventions, should go a long way in promoting safety for LEP patients. The opportunity exists for oncology to lead the way, and the information in this chapter not only makes a cogent, if not urgent case for action, it also delineates a set of actionable approaches that can make a difference for the safety of all patients, but particularly those that are vulnerable, have low health literacy, and LEP. This group of patients will make up a large percentage of the people we will see every day, as estimates indicate that minorities will comprise 48%
of the 32 million newly insured individuals as a result of the Patient Protection and Affordable Care Act (PPACA).  These patients will also be less educated, and have higher rates of LEP than the currently insured. If we are to meet the needs of our current and future patient populations, and deliver on our promise of high-quality, high-performance, high-value healthcare for all, improving the safety of LEP patients will be essential to our success.
1 Butow PN, Goldstein D, Bell ML, et al. Interpretation in consultations with immigrant patients with cancer: how accurate is it? J Clin Oncol 2011 Jul 10;29(20):2801-2807.
2 Tattersall M. Learning from experience? Lancet 2003 Nov 22;362(9397):1745.
3 Flores G, Ngui E. Racial/ethnic disparities and patient safety. Pediatr Clin North Am 2006 Dec;53(6):1197-1215.
4 Koehn PH, Swick HM. Medical education for a changing world: moving beyond cultural competence into transnational competence. Acad Med 2006 Jun;81(6):548-556.
5 Elixhauser A, Weinick RM, Betancourt JR, Andrews RM. Differences between Hispanics and non-Hispanic Whites in use of hospital procedures for cerebrovascular disease. Ethn Dis 2002 Winter;12(1):29-37.
6 Ash M, Brandt S. Disparities in asthma hospitalization in Massachusetts. Am J Public Health 2006 Feb;96(2):358-362.
7 Jiang HJ, Andrews R, Stryer D, Friedman B. Racial/ethnic disparities in potentially preventable readmissions: the case of diabetes. Am J Public Health 2005 Sep;95(9):1561-1567.
8 Chan A, Woodruff RK. Comparison of palliative care needs of English- and non-Englishspeaking patients. JPalliat Care 1999 Spring;15(1):26-30.
9 Surbone A. Cultural competence in oncology: where do we stand? Ann Oncol 2010 Jan;21(1):3-5.
10 Betancourt JR, Green AR, King RK. Improving Quality and Achieving Equity: A Guide for Hospital Leaders. Boston, MA: Massachusetts General Hospital, 2008.
11 Laidsaar-Powell RC, Butow PN, et al. Physician-patient-companion communication and decision-making: a systematic review of triadic medical consultations. Patient Educ Couns 2013 Apr;91(1):3-13.
12 Medical Interpreting Standards of Practice. International Medical Interpreters Association & Education Development Center, 2007.
13 Schapira L, Vargas E, Hidalgo R, et al. Lost in translation: integrating medical interpreters into the multidisciplinary team. Oncologist 2008 May;13(5):586-592.
14 Kai J, Beavan J, Faull C. Challenges of mediated communication, disclosure and patient autonomy in cross-cultural cancer care. Br J Cancer 2011Sep 27;105(7):918-924. PubMed PMID: 21863029.
15 Sequist TD, Fitzmaurice GM, Marshall R, et al. Physician performance and racial disparities in diabetes mellitus care. Arch Intern Med 2008 Jun 9;168(11):1145-1151.
16 Gilmer TP, Philis-Tsimikas A, Walker C. Outcomes of Project Dulce: a culturally specific diabetes management program. Ann Pharmacother 2005 May;39(5):817-822.
17 Betancourt JR, Weissman JS. Aetna's Pin Health Care Disparities: The Diabetes Pilot Program. Boston: Disparities Solutions Center, 2006.
18 Santry HP, Wren SM. The role of unconscious bias in surgical safety and outcomes. Surg Clin NorthAm 2012 Feb;92(1):137-151.
19 Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med 1999 Oct 14;341(16):1198-1205.
20 Barnholtz-SloanJS, SloanAE, SchwartzAG. Relative survivalrates andpatterns ofdiagnosis analyzed by time period for individuals with primary malignant brain tumor, 1973-1997. J Neurosurg 2003 Sep;99(3):458-466.
21 Claus EB, Black PM. Survival rates and patterns of care for patients diagnosed with supratentorial low-grade gliomas: data from the SEER program, 1973-2001. Cancer 2006 Mar 15;106(6):1358-1363.
22 Iwamoto FM, Reiner AS, Panageas KS, et al. Patterns of care in elderly glioblastoma patients.
Ann Neurol 2008 Dec;64(6):628-634.
23 Greenstein AJ, Litle VR, Swanson SJ, et al. Racial disparities in esophageal cancertreatment and outcomes. Ann Surg Oncol 2008 Mar;15(3):881-888.
24 Steyerberg EW, Earle CC, Neville BA, Weeks JC. Racial differences in surgical evaluation, treatment, and outcome of locoregional esophageal cancer: a population-based analysis of elderly patients. J Clin Oncol 2005 Jan 20;23(3):510-517.
25 MorrisAM, WeiY, BirkmeyerNJ, BirkmeyerJD. Racial disparitiesinlate survival afterrectal cancer surgery. JAm Coll Surg 2006 Dec;203(6):787-794.
26 Morris AM, Billingsley KG, Baxter NN, Baldwin LM. Racial disparities in rectal cancer treatment: a population-based analysis. Arch Surg 2004 Feb;139(2):151-155; discussion 6.
27 Murphy MM, Simons JP, Ng SC, et al. Racial differences in cancer specialist consultation, treatment, and outcomes for locoregional pancreatic adenocarcinoma. Ann Surg Oncol 2009 Nov;16(11):2968-2977.
28 Earle CC, Neumann PJ, Gelber RD, et al. Impact of referral patterns on the use of chemotherapy for lung cancer. J Clin Oncol 2002 Apr 1;20(7):1786-1792.
29 van Wieringen JC, Harmsen JA, Bruijnzeels MA. Intercultural communication in general practice. Eur J Public Health 2002 Mar;12(1):63-68.
30 Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004 Dec; 94(12):2084-2090.
31 GordonHS, StreetRL,Jr., SharfBF, etal. Racialdifferencesintrustandlungcancerpatients' perceptions of physician communication. J Clin Oncol 2006 Feb 20;24(6):904-909.
32 Etchegaray JM, Ottosen MJ, Burress L, et al. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff (Millwood) 2014 Jan;33(1):46-52.
33 Donelan K, Hobrecker K, Schapira L, et al. Medical interpreter knowledge of cancer and cancer clinical trials. Cancer 2009 Jul 15;115(14):3283-3292.
34 Banerjee AK, Okun S, Edwards IR, et al. Patient-Reported Outcome Measures in Safety Event Reporting: PROSPER Consortium guidance. Drug Saf 2013 Dec;36(12):1129-1149.
35 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.
36 Hosford SB. Hospital progress in reducing error: the impact of external interventions. Hosp Top 2008 Winter;86(1):9-19.
37 Romano PS, Geppert JJ, Davies S, et al. A national profile of patient safety in U.S. hospitals. Health Aff (Millwood) 2003 Mar-Apr;22(2):154-166.
38 Foundation RWJ. Disparities in Health Care Persist. Available at: http://www.rwjf.org/ content/dam/farm/reports/issue_briefs/2012/rwjf402390/subassets/rwjf402390_3 [accessed September 2014].
PART III Cancer patients, oncology professionals, and institutions against medical errors CHAPTER 9