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Handoffs are one of the most dangerous times in a patient’s care: As one team of caregivers passes a case to the next shift, a clinician might neglect to jot down an important observation, forget to input an order for a test before heading home, or fail to realize that a medication ordered overnight never arrived by morning.

But handoffs do not have to be so perilous, and patients and families themselves can provide a valuable safeguard against medical errors arising from these inevitable transition points. For children in particular, parents are the ones who notice when their infant’s formula was accidentally swapped, or whether their preschooler is still clutching her head in pain after it should have eased. It is with this expertise in mind that a group of physicians and researchers at 32 hospitals across the U.S. and Canada are pushing to improve the handoff procedure and bring patients and families more into the process. But providers have to be thoughtful about how they do that — especially when caring for kids whose parents and families are not proficient in English.

A new study, published Monday in JAMA Pediatrics, surveyed patients and families at pediatric units in 21 hospitals and found that those who are not proficient in English are less comfortable asking questions about their care and less likely to speak up when something does not seem right. An estimated 8.3% of people in the U.S. meet the federal criteria to be considered as having limited English proficiency.


The findings show that children and their caregivers who aren’t proficient in English are nearly two times less likely to say they are unafraid of asking questions “when something does not seem right,” four times less likely to say they “will freely speak up” if they see something that may negatively affect care, and five times less likely to say they “feel free to question the decisions or actions of health care providers.” The finding echoes past research that has shown language barriers worsen health outcomes.

“Providers and hospitals need to do a better job of making patients who don’t speak English feel safe speaking up and asking questions,” said Alisa Khan, first author of the study and a pediatrician at Boston Children’s Hospital.


To some researchers, the magnitude of the disparity was alarming — and it’s possible it could be even wider.

“I thought it might be too conservative an estimate, because in order to complete the study, you had to fill out the questionnaire on your own,” said Francesca Gany, a physician and chief of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center. Gany, who wasn’t involved in the research, said the study design means the results might have excluded “people who have even more difficulty and who have even lower literacy levels.”

Khan said the findings are particularly concerning, given that clinicians don’t consistently call in an interpreter, who can help patients feel and be heard in the clinic.

“Most of the time, providers and hospitals really don’t use interpreters when they should, including for really high-risk things like administering medicines or consenting for procedures,” said Khan.

Under federal law, hospitals have to provide translators or interpreters free of charge to anyone with limited English proficiency. But even when this mandate is followed, patients are not always treated the same during routine parts of care, like the daily “morning round” that happens during the midnight-morning handoff between shifts.

Increasingly in pediatrics, these rounds are also termed family-centered rounds, as they take place in the child’s room, with their family present.

“When I was a resident, we tended to do morning rounds completely in the conference room, away from the patient’s bedside altogether,” said Christopher Landrigan, the general pediatrics chief at Boston Children’s Hospital and a senior author of the study. Now, he involves parents by having them start and end each morning round, by avoiding medical jargon, and by asking families to summarize the discussion going on among the care team.

But patients and families aren’t always consulted in this way when an interpreter is needed, Khan said. Instead, clinicians in some of those cases “just skip family-centered rounds and round outside the room,” before having an interpreter give a high-level summary to the family, she said. That might be because it is more convenient — requesting an interpreter takes time — or because the iPads used to call in an interpreter by video are limited.

Broadly speaking, experts said, there’s growing interest in both closing disparities in care due to language access issues and in involving families in morning rounds.

“Nobody knows a child better than their parents, we should be listening to them,” said Nancy Spector, a physician and senior vice dean at Drexel University. “The doctors can’t and shouldn’t be the focus, it should be the collective team with the real emphasis on the patient,” added Spector, who was also a senior author on the study.

The team plans to publish another paper on health outcomes data, which they also collected alongside the patient and family surveys, within a year. And since their study only included people who understood Spanish, Chinese, and Arabic, they are hoping to work with additional languages too.

Khan and Spector both expressed the hope that cultural humility will become a greater aspect of care.

“Language itself is like the tip of the iceberg when you’re thinking about working with people from other backgrounds and other cultures,” Spector said. She brought up an example where a grandfather who wasn’t involved in rounds turned out to be influencing a patient’s mother to withhold medication. She was puzzled by the child’s continued sickness and only found out through a roundabout way that the child wasn’t taking her medicine.

In the meantime, before more is done to reduce language barriers in health care, experts say it is critical to encourage families to ask for an interpreter if they might need one. “What I tell families is: It’s your right to have this interpreter, and please ask for it,” said Khan. “Don’t hesitate.”

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