the safety of health care for ethnic minority …...the safety of health care for ethnic minority...

SYSTEMATIC REVIEW Open Access

The safety of health care for ethnicminority patients: a systematic reviewAshfaq Chauhan1* , Merrilyn Walton2, Elizabeth Manias3, Ramesh Lahiru Walpola1, Holly Seale1, Monika Latanik4,Desiree Leone4, Stephen Mears5 and Reema Harrison1

Abstract

Introduction: Evidence to date indicates that patients from ethnic minority backgrounds may experience disparityin the quality and safety of health care they receive due to a range of socio-cultural factors. Although heightenedrisk of patient safety events is of key concern, there is a dearth of evidence regarding the nature and rate of patientsafety events occurring amongst ethnic minority consumers, which is critical for the development of relevantintervention approaches to enhance the safety of their care.

Objectives: To establish how ethnic minority populations are conceptualised in the international literature, and theimplications of this in shaping of our findings; the evidence of patient safety events arising among ethnic minorityhealthcare consumers internationally; and the individual, service and system factors that contribute to unsafe care.

Method: A systematic review of five databases (MEDLINE, PUBMED, PsycINFO, EMBASE and CINAHL) wereundertaken using subject headings (MeSH) and keywords to identify studies relevant to our objectives. Inclusioncriteria were applied independently by two researchers. A narrative synthesis was undertaken due to heterogeneityof the study designs of included studies followed by a study appraisal process.

Results: Forty-five studies were included in this review. Findings indicate that: (1) those from ethnic minoritybackgrounds were conceptualised variably; (2) people from ethnic minority backgrounds had higher rates ofhospital acquired infections, complications, adverse drug events and dosing errors when compared to the widerpopulation; and (3) factors including language proficiency, beliefs about illness and treatment, formal and informalinterpreter use, consumer engagement, and interactions with health professionals contributed to increased risk ofsafety events amongst these populations.

Conclusion: Ethnic minority consumers may experience inequity in the safety of care and be at higher risk ofpatient safety events. Health services and systems must consider the individual, inter- and intra-ethnic variations inthe nature of safety events to understand the where and how to invest resource to enhance equity in the safety ofcare.

Review registration: This systematic review is registered with Research Registry: reviewregistry761.

Keywords: Patient safety, Patient safety events, Inequity, Ethnic minority, Healthcare disparities, Patient engagement

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* Correspondence: [email protected] of Public Health and Community Medicine, University of New SouthWales, Sydney 2052, NSW, AustraliaFull list of author information is available at the end of the article

Chauhan et al. International Journal for Equity in Health (2020) 19:118 https://doi.org/10.1186/s12939-020-01223-2

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IntroductionA multitude of factors contribute to health inequityamongst ethnic minority populations including limitedsocial support, lower health literacy, lower socio-economic status, greater incidence of ill health and asense of disempowerment [1–4]. Access to care and lan-guage barriers have been the predominant focus of re-search, with evidence of failure to provide qualifiedinterpreting services to people with limited English pro-ficiency (LEP) as a key contributor to poor care out-comes [5–12].Whilst health inequities amongst ethnic minorities

internationally are well-established, patients’ ethnicity, lan-guage and culture are increasingly recognised as signifi-cant predictors of the quality of health care delivery inaddition to health outcomes [13–16]. An emerging bodyof research indicates that patients from minority groupsare at higher risk of patient safety events,which are eventsthat could have or did result in harm to the patient, com-pared to the mainstream population [17–19].Internationally, there has been significant investment

in enhancing patient safety mechanisms across healthsystems [20] through funded international and nationalbodies responsible for patient safety in health, includingdedicated units within the World Health Organisation(WHO) and organisations such as the AustralianCommission on Safety and Quality in Health Care(ACSQHC) in Australia, the National Safety Investiga-tion Branch in the UK and the Agency for HealthcareResearch and Quality (AHRQ) in the US. Widespreadimplementation of clinical governance frameworks bythese bodies and human capital and system-level resour-cing to improve safety in care such as incident reportingand analysis among others has been notable over thepast 30 years [20–23].Despite international efforts to enhance patient safety and

care quality, there has been limited focus on improving safetyfor ethnic minority populations, which remains an under-researched area [13, 24]. Patients from ethnic minorities con-tinue to report feeling unsafe when receiving health care,with experiences of discrimination, not having appropriateinterpreting services and having inadequate knowledge ofhealthcare settings [25]. Current policy guidelines inAustralia and many countries internationally require use oftrained interpreters, yet research to date highlights patientsreliance on informal translating mediums to support theirhealthcare interactions [25]. Lack of sufficient systems sup-port comprising inadequate policies and resource formandatory use of trained interpreters may lead to poor qual-ity interactions between patients, carers and professionalsand exacerbate the risk of safety events [17].In the context of established disparities in the rate of

safety events experienced by ethnic minority and major-ity populations, the nature and rate of patient safety

events and the underpinning factors associated with safecare involving ethnic minorities are not well understood[17]. Systematic reviews of patient safety events for eth-nic minorities have been limited to only one type of pa-tient safety event, e.g. medication errors or country [26].To address the knowledge gap, we conducted a system-atic review with the following objectives:1) how ethnicminority populations are conceptualised across the inter-national literature and the implications for this concep-tualisation in shaping our findings; 2) to establish theevidence for patient safety events involving ethnic mi-nority healthcare consumers internationally; and 3) theindividual, service and system factors that contribute tosafety among ethnic minority healthcare consumers.

MethodsThe Preferred Reporting Items for Systematic Reviewand Meta-Analyses (PRISMA) statement was used toguide the reporting of this systematic review [27].

Inclusion criteriaWe included available publications in English that re-ported original, primary empirical, conceptual or theoret-ical work published from January 2000 to October 2019.Conceptual, theoretical, quantitative or qualitative studiesof any research design were eligible including systematicreviews. Studies had to include a sub- or full sample ofethnic minority patients/consumers or data related toethnic minority patients/consumers. Ethnic minority pa-tients/consumers were defined broadly to include anygroup who did not speak one of the national languages ofthe study country, were born in another country, or thosewho belonged to an ethnic minority group. Outcomes re-lating to any patient safety events were included exceptfor the specific exclusion applied below. We defined pa-tient safety event as an event that could have or did resultin unnecessary harm to the patient.

Exclusion criteriaPublications were excluded if they were not from coun-tries within the Organisation for Economic Co-operationand Development (OECD). Case reports, letters, edito-rials, and comments were excluded. Studies discussingthe following were also excluded: 1) disparity in clinicaloutcomes or health outcomes in ethnic minorities; 2)diagnostic disparities in ethnic minorities in mentalhealth settings; 3) disparities in access to health care,health prevention and health promotion activities; 4) dis-parity in quality of healthcare delivery; and 5) safety is-sues or incidents relating to multicultural healthcarestaff. Though these studies are important in understand-ing the health disparities between ethnic minorities andthe mainstream population, they present their own line

Chauhan et al. International Journal for Equity in Health (2020) 19:118 of 25

of inquiry and were considered too broad for this sys-tematic review.

Study identificationAn initial range of text words, synonyms and subjectheadings for the two concepts of this study, patientsafety events and ethnic minority, were compiled usingseveral documents as a guide [18, 28, 29]. A lack of con-sistent terminology used across studies meant that abroad range MeSH (Medical Subject Headings) termsand text words were needed to cover each concept. Forexample, the concept of patient safety events can beencompassed by subject headings and text words suchas adverse events, medication errors, diagnostic errors,as well as patient safety, among others. The concept ofan ethnic minority is encompassed by an even widerrange of subject headings and text words including cul-tural diversity, ethnic groups, minority groups and Non-English Speaking. We searched five databases (MED-LINE, PUBMED, PsycINFO, EMBASE and CINAHL).We also hand searched the reference list of the includedstudies to ensure that we included all relevant studies.

Study selection and data extractionThe database search was uploaded to Covidence system-atic review software (Veritas Health Innovation, Mel-bourne, Australia) with articles available online for initialtitle and abstract review. Based on the information avail-able in the title and abstract, one reviewer (AC) completedthe initial title and abstract review. The inclusion criteriawere then independently applied for full text review bytwo reviewers (AC; RH). Disagreements were resolved byconsultation. The following data were extracted from in-cluded studies: author, publication year, location & setting,research methodology & sample, population studied, ob-jectives and key findings.

Assessment of study qualityDue to heterogeneity of the study types included, weused a revised version of the Quality Assessment Toolfor Studies with Diverse Designs (QATSDD) with 13items [30]. The revised version was checked for reliabil-ity with two reviewers independently scoring the in-cluded studies. The Kappa test was used for inter-raterreliability [31]. The score of 0.65 was obtained and isconsidered substantial for reliability [31, 32].

Narrative data synthesisWe used a narrative synthesis to analyse our findingsdue to the heterogeneity of the study types, as a purequantitative or qualitative approach for synthesis wasnot suitable. In addition, the outcomes discussed in eachstudy were not directly comparable. The data extractionprovided us with key findings from each study. A textual

approach was used to summarise and synthesise thefindings from the included studies against the statedobjectives.

ResultsAfter removing duplicates, 1578 articles were identified.Initial title and abstract screening led to identification of225 studies. Based on the inclusion and exclusion cri-teria, two reviewers then reviewed the full text which re-sulted in 40 studies for inclusion. The reference listsearching of the included articles led of inclusion of add-itional 5 studies. See PRISMA diagram for full searchstrategy (Fig. 1).

Study characteristicsThe included studies represented various countries,health settings and a range of study methods. The stud-ies originated from the United States (US) (25), TheNetherlands (5), The United Kingdom (UK) (2),Australia (5), Canada (1), Denmark (1), Switzerland (1),Sweden (1), and Israel (1). Three studies did not specifya geographic setting. A large number of studies werebased in hospital settings (26) with others based in thecommunity such as a pharmacy (7), and primary healthsetting (5). Two studies did not specify a setting. A ma-jority of the included studies used large administrativedatasets or retrospective chart review (14) followed byqualitative studies conducting explorative analysis of pa-tient safety events (8) and systematic reviews (8). Sum-mary of the study findings are presented in Table 1.

Study qualityOverall, the included studies varied against the qualityassessment criteria. Most studies achieved the total pos-sible score for criteria relating to: statement of aims, ob-jectives or goals; study design being appropriate toaddress research aims; format of data collection tool toaddress research aims; method of data analysis; and dis-cussing strengths and limitations. Most studies achieveda nil score against the quality criteria for the involve-ment of consumers or stakeholders in the research de-sign and conduct. Only two studies described anyinvolvement of consumers or stakeholders in the processof study design and conduct [46, 51]. Our findings high-lights lack of reporting of engagement of stakeholdersand ethnic minority consumers in research that con-cerns ethnic minority groups. The included studies pro-vided evidence around the following key areas: I) linkbetween patient safety events and the description of eth-nic minorities in the given context; II) the disparity iniatrogenic infections, complications and medicine-related safety events relating to the process of healthcare; and III) various factors influencing safety eventssuch as communication barriers, cultural factors.


Review Q 1: how ethnic minority populations areconceptualised across the international literature andwhat are the implications of this conceptualisation inshaping our findings?Three studies defined or included a definition of ethnicminority [26, 33, 69]. Minority populations were gener-ally conceptualised in the following ways (1): by race,such as African Americans, Caucasians, Asians (2); bylanguage, such as Spanish speaking, Low English Profi-ciency (LEP); and/or (3) country of origin. Most studiesused one or two of the methods to define their ethnicminority populations of study [41, 66, 68]. Large admin-istrative dataset studies largely used race as the key de-terminant [62, 66]. The methods used reflect the dataavailable in major databases or routinely collected.

Review Q 2: what is the evidence for patient safety eventsinvolving ethnic minority healthcare consumersinternationally?The nature and severity of adverse events and disparityin the occurrence of these events was examined in thir-teen studies, primary emerging from the US. Differencesbetween ethnic minority patients and others in safetyevents were predominantly examined using large admin-istrative datasets, retrospective record reviews and sys-tematic reviews focused on rates of (i) hospital acquiredinfections (HAIs), (ii) complications in care and (iii) ad-verse drug events (ADEs) [15, 35, 37, 39, 48, 56–59, 62,66, 69, 71].Five retrospective studies using large administrative

datasets, three using the Patient Safety Indicators (PSIs)as outcome measures [39, 62, 66] and two using Medica-tion Patient Safety Monitoring System (MPSMS) [15, 57]

explored the rate of various HAIs and ADEs among pa-tients from different ethnic backgrounds. These studiesreported mixed results highlighting that some ethnicgroups were at greater risk of some patient safety events.For example, in a review of administrative data from 16states in the US, African Americans were reported tohave 1.25 to over 1.5 times the rate of infections, postop-erative sepsis, decubitus ulcers, postoperative respiratoryfailure, postoperative pulmonary embolism or deep veinthrombosis (PE/DVT) as Caucasians even when control-ling for income level [39]. Findings also revealed thatHispanics had 1.25 to 1.50 times the rate of sepsis andphysiologic and metabolic derangements as Caucasians;and Asian/ Pacific Islanders had 1.25 to 1.50 times therate of sepsis, haemorrhage or hematoma, respiratoryfailure, and physiologic and metabolic derangement [39].Further US studies reported disparities in a range ofsafety indicators for African American and Asian /PacificIslander peoples [57, 66]. Yet in the Netherlands, a studyof 763 Dutch patients and 576 ethnic minority patientsrevealed no difference in the rate of adverse events be-tween the groups [71]. When compared to the US stud-ies, the authors explained this as being due to theavailability of equal access to care through a mandatoryinsurance scheme for patients [71].The evidence relating to ADEs among ethnic minor-

ities was mixed and was observed to depend on context-ual features such as geographical, genetic and culturalfeatures [35, 57, 59]. Metersky et al. in their retrospect-ive review of 102,623 charts in US hospital settingsfound that the risk-adjusted odds of African Americanpatients suffering an ADE compared with Caucasian pa-tients was 1.29 (95% CI, 1.19–1.40) [57]. Baehr et al. in

Fig. 1 PRISMA Flow Diagram


Table 1 Summary of study findings

Authors Year Setting/Country

Method/Sample

Ethnic minorityconceptualisation

Aims/Objectives Relevant Findings

Alhomoudet al [26]

2013 UKCommunitysetting

Systematic Reviewn = 15 articles

Ethnic minorities.Defined as groups whoshare minority status intheir country of residencedue to ethnicity, place ofbirth, language, religion,citizenship and othercultural differences.

a) Establish types andcauses of medicine relatedproblems (MRPs)b) Identifyrecommendations insupport of effective use ofthese medications.

• Differing culturalperceptions and beliefsabout health, illness,prescribed treatment andmedical care impact onthe use of medicine.

• Lack of awareness of theextent of patients’decision-making regard-ing the use of their medi-cines and/or poorappreciation of their ex-perience of MRPs, maycause MRPs

• Recommendationsidentified involvededucation, use ofinterpreters, bilingualworkers to bridge thecultural divide and toencourage participationof minority communitiesin decision-making.

Alhomoudet al [33]

2015 UKCommunitysetting(pharmacy)

Face to face semi-structured interviewsn = 80

South Asian and MiddleEastern patients

a) To describe medicinerelated problemsb) Identify contributingfactors

• Religious practices andbeliefs, use of non-prescription medicines,extent of family support,and travelling abroad--topatient’s homeland or totake religious journeyswere identified as factorsspecific to SA and MEpatients.

• Illiteracy, language andcommunication barriers,lack of translatedresources, perceptions ofhealthcare providers, anddifficulty consulting adoctor of the samegender may alsocontribute to MRPs.

Ajdukovicet al [34]

2007 AustraliaHospitalsetting (ED)

Interviews with patients.n = 100 patients (24with language barrier)

Patient subgroups;‘general’ patients, patientswith a ‘language barrier’and patients from aresidential aged carefacility.

a) To identify medication-related ED presentationsand describe the incidencein these demographicgroups.

• The number of correctlyrecorded medicationswas lowest in the‘language barrier’ group(13.8%) compared with 18and 19.6% of medicationsfor ‘general’ patients andpatients from residentialaged care facilitiesrespectively.

Baehr et al[35]

2015 USAll settings

Systematic Reviewn = 40 articles.

Low English Proficiency(LEP)

a) To synthesize existingliterature in order tounderstand the state ofevidence for racial andethnic disparitiesassociated with ADEs inthe USAb) To identify gaps inexisting knowledge inorder to target futureresearch.

• Asian race was associatedwith an approximatelyfourfold risk ofanticoagulant relatedADEs such as bleeding,haemorrhage.

• African Americans werethe most commonlyidentified group at risk forADEs caused by diabetesagents such ashypoglycaemia.

• Caucasians were mostfrequently identified as at


Table 1 Summary of study findings (Continued)


Method/Sample



risk for opioid relatedADEs such as overdose.

• Opioid related side effectswere noted in 58% ofAfrican Americans ascompared to Caucasians.

Bakullari et al[15]

2015 USHospitalSetting

Retrospective chartreviewn = 79,019

Six racial/ethnic groups. a) To determine whetherracial/ethnic disparitiesexist in the rate ofoccurrence of HealthcareAcquired Infectionscaptured in the MedicarePatient Safety MonitoringSystem (MPSMS).

• The occurrence rate forHAIs was 1.1% forCaucasians, 1.3% forAfrican Americans, 1.5%for Hispanic patients, 1.8%for Asian patients, 1.7%for Native Hawaiian/Pacific Islander patients,and 0.70% for otherpatients.

• Compared withCaucasians patients, theodds ratios of occurrenceof HAIs were 1.1 (95%confidence interval [CI],0.99–1.23) for AfricanAmericans, 1.3 (95% CI,1.15–1.53) for Hispanics,1.4 (95% CI, 1.07–1.75) forAsians.

Blennerhassetet al [36]

2011 AustraliaCommunitySetting(Pharmacy)

Multistage qualitativestudyInterviews with patients(n = 18) and focusgroups (n = 9) with staff.

Greek [5], Russian [5],mandarin or Cantonese [4]and English [4] speaking.

a) Examine medicinemanagement in olderpeople from Non-English-speaking background.

• Patients lack knowledgeabout medications andmedication changes.

• Interpreter services notroutinely used.

• Lack of systematic,standardized processesfor identifying people atrisk of medicinemismanagement or forthe implementation ofactions to minimise risks.

Bloo et al [37] 2014 Country notapplicableHospitalsetting

Systematic reviewn = 26

Ethnic minorities a) Review the literature onsafety differences betweenpatients from minorityethnic groups and thosefrom the ethnic majorityundergoing surgery.

• Minority ethnic groupshad statistically significanthigher complication ratescompared with the ethnicmajority.

• Higher incidence ofinfection and graftrejection among ethnicminorities

• Higher incidence of painand re-operation amongethnic minorities.

Cantarero-Arevalo et al[38]

2014 DenmarkCommunitysetting

Before and after study.Mixed Methods.Participants: Pre n = 30Post n = 23

Arabic speaking from 10different countries.

a) To explore theperceptions, barriers andneeds of Arabic-speakingethnic minorities regardingmedicine useb) To use an educationprogram to enhance theknowledge andcompetencies of theethnic minorities about theappropriate use ofmedicines

• Misconceptions relatingto medication use,mistrust with Danishdoctors and lowcompliance to doctor’srecommendations wereidentified as barriers tocorrect medicine use.

• A culturally competenteducation program maypotentially reducemedicine-relatedproblems.

Coffey et al 2005 US Quantitative Study Three racial/ethnic a) To determine whether • Each ethnic minority




Method/Sample



[39] Hospitalsetting

Sixteen Sate sample. minorities group (Black,Hispanics & Asian/PacificIslanders)

racial and ethnicdifferences between inpatient safety eventsdisappear when income isconsidered.

group has a higher rateof nosocomial infections,post-operative sepsis and2 post-operativecomplications.

• African Americans have1.25 to 1.5 times the rateof infection due tomedical care,postoperative sepsis,decubitus ulcers,postoperative respiratoryfailure and PE/DVT asCaucasians.

• Hispanics have 1.25 to1.50 times the rate of 2post-operative complica-tions as Caucasians.

• Asian/Pacific Islandershave 1.25 to 1.50 timesthe rate of 4 post-operative complications.

Cohen et al[40]

2005 USHospitalsetting:Paediatric.

Case control studyCases, n = 97Ctrl, n = 475

Language barrier definedby self- or provider-reported need for aninterpreter.

a) Determine whetherhospitalized paediatricpatients whose familieshave language barriers aremore likely to incur seriousmedical errors thanpatients whose families donot have language barriers

• No increased risk forserious medical events inpatients and families whorequested an interpretercompared with patientsand families who did notrequest an interpreter(odds ratio: 1.36; 95%confidence interval: 0.73–2.55).

• Spanish speaking patientswho requested aninterpreter had two-foldincreased risk of adverseevents compared withpatients who did not re-quest an interpreter.

• All other language groupscomposed of < 1%patient population andhad no detectableincreased risk of adverseevents.

Divi et al [41] 2007 USHospitalsetting.

Quantitative analysis ofAEs incident reportsn = 1083

Low English proficiently –LEP

a) To examine differencesin the characteristics ofadverse events betweenEnglish speaking patientsand patients with limitedEnglish proficiency in UShospitals.

• Overall, 29.5% of reportedadverse events in Englishspeaking patients and49.1% of reported adverseevents in LEP patientscaused some physicalharm to the patient

• LEP patients experienceda statistically significantlygreater proportion ofadverse events that wereattributable tocommunication failure(52.4%) than did Englishspeaking patients (35.9%).

• LEP patients experienceda statistically significantlygreater proportion ofevents attributable toquestionable advice/interpretation than




Method/Sample



English speaking patients(11.2 vs. 3.5%).

• Overall, system factorswere found to play astatistically significantlygreater role in theoccurrence of adverseevents for LEP patientsthan for English speakingpatients especially, theywere more attributable toorganisational factors.

• Adverse events associatedwith practitioner factorsoccurred more often toLEP patients than toEnglish speaking patients.

Flores et al[42]

2003 USHospitalsetting:Paediatrics

Analyses of audiotapedinterpreter encountersn = 13

Spanish speaking a) To determine thefrequency, categories andpotential clinicalconsequences of errors inmedical interpretation.

• Sixty three percent of allerrors had a potentialclinical consequence.

• Errors committed by adhoc interpreters weremore likely to result in asignificant clinicalconsequence ascompared to hospitalinterpreters.

• Errors of clinicalconsequence included: 1)omitting questions aboutdrug allergies; 2) omittinginstructions on the dose,frequency, and durationof antibiotics andrehydration fluids; 3)adding thathydrocortisone creammust be applied to theentire body, instead ofonly to facial rash; 4)instructing a mother notto answer personalquestions; 5) omittingthat a child was alreadyswabbed for a stoolculture; and 6) instructinga mother to putamoxicillin in both earsfor treatment of otitismedia.

Flores et al[43]

2012 USHospitalsetting:Paediatrics

Analyses of audiotapedencounters (n = 57), 20with professionalinterpreters, 27 with adhoc interpreters and 10with no interpreters.

Spanish speaking limitedEnglish proficiencypatients, caregivers,families and theirinterpreters

a) To compare interpretererrors and their potentialconsequences inencounters withprofessional vs ad hoc vsno interpreters.

• The proportion of errorsof potential consequencewas significantly lower forprofessional (12%) versusad hoc (22%) versus nointerpreters (20%).

• Among professionalinterpreters, previoushours of interpretertraining, but not years ofexperience, weresignificantly associatedwith error numbers, types,and potentialconsequences.

• Interpreters with greater




Method/Sample



than or equal to 100 h oftraining committedsignificantly lowerproportions of errors ofpotential consequenceoverall (2% versus 12%)

Fejzic et al[44]

2004 AustraliaCommunitySetting

Mixed methodn = 25 NESB patients

NESB – residents of formerYugoslavia now residing inAustralia.

a) Medicationmanagement reviews(MMR) in people from aNESB in their nativelanguage in order toidentify medication-relatedproblems

• Psychological andsociological factors wereidentified as havingsignificant impacts onmedication management.

• Not understanding howto take medications,unknown side effects, norecognition ofprofessional help, takingparacetamol wrong wereidentified as some of themain medication relatedproblems.

Goenka [45] 2016 USNotspecified

Literature ReviewSample size notavailable.

Low English Proficiency(LEP) patients

a) To summarize the legalbasis for providinglanguage access in thehealthcare setting, discussthe impact ofinterpretation services onclinical care, and explorethe effects of languagebarriers on healthoutcomes

• There is often anoverestimation ofpatients’ Englishproficiency leading toinadequate languageassistance.

• The lack of interpretation,or use of informal,untrained interpreters, hassignificant effects onpatient safety, quality ofcare, and patientsatisfaction.

• The inconsistencies incommunication appear tohave a direct impact onthe incidence of adverseevents.

• Children with LEP parentsare twice as likely toexperience a preventableadverse drug event.

Hadziabdicet al [46]

2011 SwedenCommunitysetting:primaryhealth care

Qualitative analysis ofincidents(n = 60 incidents)

Person of foreignbackground.

a) To explore whatproblems are reported byprofessionals in primaryhealthcare concerning theuse of interpreters andwhat the problems lead to.

• Incident reports analysishighlighted problemsfaced by health careprofessionals due to lackof available interpretersand also lack ofinterpreters’understanding ofSwedish.

• The main problemsdocumented were relatedto language, such as lackof the interpreters withproficiency in a particularlanguage, and toorganisational routines,with difficulties in theavailability of interpretersand access to theinterpreter agency.

• Consultations werelimited possibilities tocommunicate and thusconsultation was carried




Method/Sample



out without a professionalinterpreter, using familymembers instead.

Harris et al[47]

2017 USOutpatientclinicalsetting –Paediatrics.

Cross-sectional analysisof data from multisiterandomized controlledexperimentn = 1126

Self-identified as Hispanics a) To examine associationsbetween health literacy,LEP, and liquid medicationdosing errors in Hispanicparents.

• Liquid medication dosingerrors by Hispanic parentsare common, with over80% of parents making atleast one error, and thaterrors were morecommon among thosewith limited healthliteracy and LEP.

• Efforts to revise existingstandards or to redesignpaediatric medicationlabels and dosing toolsshould be specificallytailored to meet theneeds of limited literacyand LEP individuals.

Hernandez-Suarez et al[48]


National InpatientSample (NIS) databasefilesn = 36,270

Caucasians, AfricanAmericans and Hispanics.

a) To identify racial/ethnicdisparities in utilizationrates, in-hospital outcomesand health care resourceuse among Non-HispanicWhites (NHW), AfricanAmericans (AA) and His-panics undergoing TAVR

• Hispanic patients hadhigher in-hospitalcomplications.

• Hispanic was associatedwith higher incidence ofacute myocardialinfarction (aOR = 2.02;95%CI, 1.06–3.85;P = .03),stroke/transient ischemicattack (aOR = 1.81; 95% CI,1.04–3.14;P = .04), acutekidney injury (aOR = 1.65;95% CI, 1.23–2.21;Pb.01).

Inagaki et al[49]

2017 USHospitalsetting

Retrospective recordreview(Patients: Non-EnglishSpeaking - 51, Englishspeaking – 210)

Non-English Speaking a) To evaluate the effect oflanguage discordance onpost-operative outcomesamong vascular surgerypatients.

• Adjusted analysis showedthat languagediscordance did not affectthe odds of adverseoutcomes of woundinfections or adverse graftevents.

Karliner et al[50]


Participant surveyfollowed by a phoneinterviewn = 308 participants

LEP – Low EnglishProficiency (English,Spanish and Chinese)

a) Was language barrier isassociated with lower ratesof understanding ofdischarge instructions,including diagnosis, typeof follow-up appointments,and medication categoryand purpose after dis-charge from the acute carehospitalb) Was languageconcordance andinterpretation at dischargeassociated withunderstanding of dischargeinstructions.

• Most LEP patients’understanding ofmedications and of thetype of follow-up ap-pointment was low.

• Language concordantdischarge instructions hadlower odds ofunderstanding foroutcomes related toappointment type andcombined medicationcategory and purpose.

• LEP participants reportinga family/friend interpreterat discharge had lowerodds of understandingtheir medications.

• LEP participants reportingno interpretation atdischarge had similaroutcomes to the English-speaking group.

• Number of medicationswas associated with lower




Method/Sample



rates of medicationunderstanding regardlessof other factors and eachadditional medicationwas associated with a 10–15% reduction in rate ofany kind of medicationunderstanding.

Koster et al[51]

2014 TheNetherlandsCommunitysetting

Cross-sectional study(quantitative survey) of691 non-Dutch speakingmigrants.

First generation migrants.*(Antilles, Persians,Surinamese and Turks)

a) Assess interpretation ofdrug label instructions indifferent migrantpopulations living in theNetherlands.

• Many standardly useddrug label instructions areunclear, andmisinterpretation of theseinstructions occurs bothin highly educatednatives and immigrants.

• Turkish migrants mostoften experiencedproblemswithcomprehension ofthe tested instructions.

• Information presented onthese labels is verylimited, and these labelsare only effective ifpatients are able tounderstand instructions,interpreted theinformation correctly, andcan follow the adviceprovided on them.

• Lower understanding ofdrug labels forSurinamese and Antilleanmigrants compared tothe reference group wasnot observed as Dutch isalso an official languagein these countries.

Lee et al [52] 2015 USCommunitySetting

A pre- postsurvey study.(n = 68)

Korean adult migrants a) Investigate theknowledge andunderstanding of olderadult Korean immigrantsconcerning prescriptionand over-the-countermedication directions.

• Even when information iscommunicated in nativelanguage, there is a lackof understanding ofmedication directio

Lion et al [53] 2013 USHospitalsetting:Paediatrics

Retrospective chartreview of 33,885admissions

Self-reported primarylanguage spoken was usedto identify participantsbecause no data onEnglish proficiency wereavailable for the studyperiod.

a) To evaluate the risk forserious/sentinel adverseevents among hospitalizedchildren according to race,ethnicity, and languageand to evaluate factorsaffecting length of stayassociated with serious/sentinel adverse events.

• Hospitalized children fromSpanish speaking familieshad significantly longerhospital stays inassociation with anadverse event and mayhave increased odds of aserious or sentinel event.

• Results according toethnicity were similar butsomewhat attenuated,suggesting that languagedifference, rather thanHispanic/Latino ethnicity,was the operative factor.

Lopez et al[54]


Retrospective cohortstudyn = 4,224,564 (13%)were LEP.

Self-reported LEP status a) Are hospitalized LEPpatients receivinginterpreter services duringhospital clinicalencounters?

• Results indicate that in awell-resourced academichospital, use of inter-preters by clinical staff re-mains highly variable,




Method/Sample



with 66% of LEP patientshaving no interpreter useduring the inpatient clin-ical encounter.

Masland et al[55]

2011 USCommunitysetting

Cross-sectional surveyn = 48,968 surveys

Mexicans, CentralAmericans, Chinese,Koreans, and Vietnamese.

a) Examine the effect oflanguage and culturalfactors on prescriptionlabel understanding byethnic groups.

• In multivariate analysis,limited English increasedodds of difficulty inunderstandingprescriptions by threetimes for Mexicans,Central Americans, andKoreans, and four timesfor Chinese; it wasinsignificant forVietnamese.

• In controlled analysis,Chinese and Koreanethnicity increased oddsof difficulty ofunderstanding comparedto Mexican or CentralAmerican ethnicity;Vietnamese ethnicityreduced odds of difficultycompared to others.

• Having a bilingual doctorreduced odd of difficultywhile disability, loweducation, low income orrecent immigrationincreased odds ofdifficulty.

McDowellet al [56]

2006 Country notapplicableAll settings

Systematic review andmeta-analysisn = 24

Studies identifying at least2 ethnic groups with oneor more ADRs.

a) To review the evidencefor ethnic differences insusceptibility to adversedrug reactions (ADRs) tocardiovascular drugs

• The relative risk of angio-oedema from angiotensinconverting enzyme (ACE)inhibitors in African Amer-icans compared withnon-African American pa-tients was 3.0 (95% CI 2.5to 3.7)

• The relative risk of coughfrom ACE inhibitors was2.7 (1.6 to 4.5) in EastAsian compared withwhite patients

• The relative risk ofintracranial haemorrhagewith thrombolytic therapywas 1.5 (1.2 to 1.9) inAfrican Americanscompared with non-African American patients

Metersky et al[57]


Retrospective chartreviewn = 102,623

Ethnic minority.African Americans andCaucasians

a) Determine racialdisparity in the frequencyof adverse events in theMedicare Patient SafetyMonitoring System

• The risk-adjusted odds ofAfrican American patientsuffering a hospital-acquired infection, or anadverse drug event com-pared with a Caucasianpatient were 1.34 (95% CI,1.17–1.55) and 1.29 (95%CI, 1.19–1.40), respectively.

• The risk-adjusted odd ra-tios were 0.94 (95% CI,0.85–1.04) and 0.94 (95%CI, 0.78–1.13) for generalevents and procedure-




Method/Sample



related adverse events,respectively.

Nwachukwuet al [58]

2010 Country notapplicableHospitalsetting

Systematic Reviewn = 9

Ethnic minorities a) To assess if theminorities have morecomplications than whitesdo after total hip re-placement and total kneereplacement.

• Racial and ethnic minoritygroups appear to have ahigher risk for earlycomplications (thoseoccurring within ninetydays), particularly jointinfection, after total kneereplacement.

• There was no significantdifference betweenAfrican Americans andCaucasians for infectionrate associated with totalhip replacement.

Okoroh et al[59]

2017 USSetting notapplicable

Systematic reviewn = 24

Ethnic minorities a) Explore differences inreporting race/ethnicity instudies on disparities inpatient safety assessadjustment forsocioeconomic status,comorbidity, and diseaseseverity

• Eight studies includedrace/ethnicity in baselinecharacteristics andadjusted for confounders.

• Hospital-level variationswere infrequentlyanalysed.

• The evidence on theexistence of disparities inthe adverse events wasmixed.

Patel et al [60] 2002 CanadaSetting notspecified

Mixed method study –three group ofparticipants.Grp 1: 8 Kenyan and 5Canadians.Grp 2: 25 English, 7 EastIndians and 16 Greekparents.Grp 3: 8 English, 7 EastIndians and 16 Greek

Different ethnic andcultural backgrounds.

a) Investigate andcharacterize the errors incognitive processesdeployed in thecomprehension ofprocedural texts found onpharmaceutical labels bysubjects of differentcultural and educationalbackgrounds.

• All participants read andinterpreted thepreparation instructionsfor the ORT correctly,regardless of culturalbackground and level offormal education.

• Only three of the eight(37.5%) Kenyan motherswere able to correctlyadminister the treatment.

• The Canadian motherswere more accurate intheir administration of thetreatment.

• Overall, cultural andeducational backgroundappeared to be onlyweakly related to theaccuracy of dosage andadministration

• All groups of participantshad considerable difficultyin interpreting theinstructions

Raynor [61] 2016 USClinicalsetting:Paediatric

Survey(n = 36)

Spanish and Arabicspeaking

a) Identify factors affectingcare in NES patients andfamilies

• Fifty percent respondentsanswered that hat theydid not know why theywere seeing that provider,did not understand thetests, or had difficultywith interpreters.

• Barriers tocommunication can leadto adverse medicaloutcomes, poorcompliance with therapy,and poor understanding




Method/Sample



of medical conditions.

Romano et al[62]


Quantitative analysis of1995–2000 HealthcareCost and UtilizationProject (HCUP)Nationwide InpatientSample (NIS).Sample size notavailable

Population wide. a) To presents nationaldata on the incidence ofPatient Safety Incidentsover time and theirassociation with patientand hospital characteristics.

• African Americaninpatients had a higherrisk of most medical andnursing-related postoper-ative complications (suchas decubitus ulcer; infec-tion following infusion, in-jection, or transfusion;and postoperative physio-logic and metabolic de-rangements, thrombo-embolism, and sepsis).

• Mortality-related eventsand the rarest sentinel-event indicators weresimilarly frequent acrossracial/ethnic categories

Samuels-Kalow et al.[63]

2013 USHospitalsetting –Pediatric ED

Prospectiveobservational study(n = 146)

Spanish speaking. a) To examine therelationship betweenlanguage and dischargecomprehension regardingmedication dosing.

• Fifty-four percent ofSpanish-speaking parentshad a dosing error, ascompared with 25% ofEnglish-speaking parents(odds ratio [OR], 3.7; 95%confidence interval [CI],1.6Y8.1).

• Half of the Spanish-speaking parents dis-charged in English (dis-cordant discharge) had adosing error, as comparedwith 62% of those dis-charged in Spanish.

• Spanish-speaking parentswere significantly morelikely to have a dosingerror (odds ratio, 3.7; 95%confidence interval,1.6Y8.1), even after adjust-ment for language of dis-charge, income, andparental health literacy(adjusted odds ratio, 6.7;95% confidence interval,1.4Y31.7)

Schwappachet al [64]

2012 SwitzerlandCommunitysetting:Pharmacy

Cross-sectional survey(n = 498)

Foreign language patients a) Investigate Swiss publicpharmacists’ experiencesand current practices incounselling foreign-language patients (FL) witha focus on patient safetyand to identify needs forsubsequent improvementactivities.b) Examine whetherfrequent experience ofcommunication barriers isassociated withpharmacists’ satisfactionwith quality of careprovision.

• Approximately 10% ofpharmacies reported thatthey at least weekly fail toexplain the essentials ofdrug therapy to FLpatients

• Ad-hoc interpreting byminors is also commonfor a considerable num-ber of pharmacies (26.5%reported at least oneweekly occurrence)

• Tools for supportingcommunication with FLpatients are used onlyinfrequently and by aminority of pharmacies –with printing informationin foreign language asthe most common tool.

• The main strategy used




Method/Sample



by pharmacists toimprove the quality ofmedication counsellingfor FL patients was thesystematic employmentof multilingual staff.

Shadmi et al[65]

2013 IsraelHospitalsetting

ProspectiveObservational study(n = 385)

Russian speaking patients a) Examine the quality ofcare transitions of minoritypatients (immigrants)versus the generalpopulation and assess theassociation between in-hospital provider–patientcommunication and thequality of minority caretransitions.

• Russian speakers reportedlower scores forunderstanding thepurpose of taking theirmedications.

Shen et al[66]


Cross-sectional study ofhospital dischargesrelated with Patientsafety indicators (n = 3,052,268)

Ethnic minority a) Are minority patientsweremore likely to incuradverse PSIsthan their Whitecounterparts;b) Are patients withMedicaidor uninsured weremore likely toincur adverse PSIs thanpatientscovered by privateinsurance.

• As compared with Whitepatients, African Americanpatients were more likelyto experience pressureulcer, postoperativehemorrhage orhematoma, and post-operative pulmonary em-bolism (PE) or deep veinthrombosis (DVE).

• Asian/Pacific Islanderpatients were more likelyto experience pressureulcer, post-operative PE orDVT, and two obstetriccare PSIs.

• Hispanic/Latino patientswere more likely toexperience post-operativephysio-metabolic de-rangement and accidentalpuncture/ laceration.

Stockwell et al[67]


Multisite investigationusing record review(N = 3790)

Ethnic minorities identifiedin records

a) To understand patientsafety disparities not beenpreviously identified in thepediatric inpatientenvironment by measuringrates of clinically confirmedAEs

• Compared withhospitalized Caucasianschildren, hospitalizedLatino childrenexperienced higher ratesof all AEs (Latino: 30.1 AEsper 1000 patient daysversus white: 16.9 AEs per1000 patient days;P ≤ .001), preventable AEs(Latino: 15.9 AEs per 1000patient days versus white:8.9 AEs per 1000 patientdays; P = .002), and high-severity AEs (Latino: 12.6AEs per 1000 patient daysversus white: 7.7 AEs per1000 patient days;P = .02).

• No significance differencewas observed in othergroups.

Suurmondet al [17]

2010 TheNetherlandsHospitalsetting

Qualitative semi-structured interviews(n = 12) for a total of 30cases

Foreign language speaking a) Explore thecharacteristics of in-hospital care and treat-ment of immigrant pa-tients to better understand

• Health care professionalspreferred ad hocinterpreters or nointerpreter at all.

• There was limited




Method/Sample



the processes underlyingethnic disparities in patientsafety.

availability of translateddocuments for patientswho do not speak or readDutch.

• Lack of insurance wasidentified as a barrier toreceiving appropriatecare.

• Organisationsshortcomings tounderstand genetic andphysical characteristics ofmigrants increases therisk of patient safetyevents.

• Presumptions about thecultural background ofthe patient resulted in anadverse event or patientsafety event.

Thomas et al[68]

2010 AustraliaHospitalsetting

Retrospective analysis of4751 charts

Culturally and linguisticallydiverse*Those born outsideAustralia /New Zealand,non-English speaking, non-Caucasian and refugees

a) Determine whetherCALD parameters,including country of birth,race, primary languagespoken, need for aninterpreter and refugeestatus are independentpredictors of obstetric orneonatal outcomes.

• Use of interpreter serviceswas associated with areduced likelihood of anadverse outcome (P =0.015),.

• No significant differenceobserved betweenadverse outcomes andrefugee status.

Timmins et al[69]

2002 USAll settings

Systematic review (n =14)

Latinos* all persons living in theUnited States whoseorigins can be traced tothe Spanish- speakingregions of Latin America,including the Caribbean,Mexico, Central America,and South America”

a) Provide knowledge forproviders and institutionsin devising effectivestrategies for bridging thelanguage barrier.

• Health care providersneed to educatethemselves and theirinstitutions about thelaws and regulations thataddress language accessin their own particularsetting

• Bilingual fieldworkersneed to be trainedappropriately to be usedfor bridging thecommunication gap.

van Rosseet al [70]


Mixed method studyRecord review (n = 567)Patientquestionnaire (n = 576)Qualitative data (n = 17)

Ethnic minoritybackground

a) At which momentsduring hospitalization dolanguage barriersconstitute a risk for patientsafety?b) How are languagebarriers detected andreported in hospital care?c) How are languagebarriers bridged in hospitalcare? What is the policyand what happens inpractice?

• In 30% of the patientsthat reported a low Dutchproficiency, no languagebarrier was documentedin the patient record.

• Relatives of patients oftenfunctioned as interpreterfor them and professionalinterpreters were hardlyused.

• Drop-out of protocolisedname and DOB checkwas observed amongpeople with low Dutchproficiency.

• Language barrierthreatened patient safetyduring daily nursing tasks(i.e. medicationadministration, painmanagement, fluidbalance management)and patient–physicianinteraction concerning




Method/Sample



diagnosis, riskcommunication andacute situations.

van Rosseet al [71]


Prospective cohortstudy(n = 763 Dutch patientsand 576 ethnic minoritypatients)


a) To compare incidence,type, nature, impact andpreventability of AEsduring hospitalisation ofDutch patients with thoseof ethnic minority patients.b) To assess the extent towhich patient-related de-terminants (language profi-ciency, health literacy,education and religion) arerelated to the incidence ofAEs among Dutch and eth-nic minority patients.

• No significant differencein the incidence of AEs:11% (95% CI 9 to 14%) inDutch patients and 10%(95% CI 7 to 12%) inethnic minority patients.

• There was no significantdifference in theincidence of preventableAEs: 3% (95% CI 1 to 4%)in Dutch patients and 1%(95% CI 0 to 2%) in ethnicminority patients

• Low language proficiency,inadequate health literacyand low educational leveldid not increase the riskof an AE.

van Rosseet al [70, 72]


Mixed method studyDocument analysis (n =20 cases)Observations (n = 3cases)Qualitative interviews(n = 12)


a) Explore the potentialroles that relatives take onthemselves and theirinfluence on patient safetyof hospitalised ethnicminority patients.

• Apart from fulfilling theirusual role as a visitingfamily member, relativesoften took on the role ofthe interpreter, thepatient and the careprovider.

• Four roles can helpoptimise quality anddecrease safety risks forthe hospitalised patientbut can also increasepatient safety risks.

• Good understandingbetween the healthcareprovider(s) and therelatives tended toincrease patient safety.

Wassermanet al [73]


Mixed method studyAnalysis of 39,133 AEsfrom char reviewInterpreter analysis of 28incidentsQualitative interviews(sample not provided)

Low English proficiency(LEP)

a) To describe thedevelopment, content, andtesting of two newevidence-based Agency forHealthcare Research andQuality (AHRQ) tools forLEP patient safety.

• Integration of interpretersis a complex processrequiring staff trainingand organizationalchange.

• LEP patients have bettersafety outcomes wheninterpreters are used butthe uptake of theinterpreters by healthprofessionals is notoptimal.

• Inconsistent collection ofpatient data on race,ethnicity, and languagegreatly affectsunderstanding the role oflanguage and culture inpatient safety events.

• Majority (60%) of theinterpreter pilot relatedevents were related tomisuse of interpreterservices.

White et al[12]

2012 AustraliaPrimary

Focus groups (n = 2)with

Chinese and Vietnameseimmigrant

a) How aging homemedicine review (HMR)-

• Chinese participants haddoubts about the


their systematic review observed that Asians were moreprone to ADEs related to anticoagulants such as bleedingand African American to ADEs relating to diabetes agentssuch as hypoglycaemia [35]. The term Asian representedcombined Asian/Pacific Islander group but authors didnot specify any specific ethnic minority group from Asia.Baehr et al. and Okoroh et al. in their systematic reviewsalso noted increased risk of certain ADEs among certainethnicities for some drugs and contributed these to gen-etic predisposition and overuse [35, 59].Five systematic reviews concerning adverse events in

surgical patients and ADEs were also included [35, 37,56, 58, 59]. In their systematic review and meta-analysesof 26 studies relating to complications and mortality insurgical care, Bloo et al. found that ethnic minoritieshave a higher risk of complications in perioperative careas compared to the ethnic majority patients resulting ina higher incidence of pain and re-operation [37]. Someincluded studies in their review discussed the causativefactors of the differences in the outcome and rangedfrom sociocultural, biological and presurgical risk factorsbut noted that these were mostly speculative highlight-ing the need for further analyses of the factors at patient,physician and system level [37].Medicine-related problems were further discussed in

eleven included studies [12, 26, 33, 34, 38, 44, 47, 51, 55,61, 63]. with a range of multifactorial issues identified[12, 33, 47]. Dosing errors were highlighted as the mostcommon error, especially in the context of children re-ceiving the wrong dose by parents from ethnic minor-ities [47, 51, 55, 63]. Harris et al. in their cross sectionalanalysis of data from a randomised controlled experi-ment, identified that greater than 80% of the Hispanic

parents made at least one dosing error related to liquidmediation dosage [47]. They observed that the rate ofdosing errors was almost double for parents with LEPand low health literacy [47]. In their systematic reviewbased in the UK, Alhomoud et al. demonstrated thatmost common medicine-related problems among ethnicminority group in the UK were not taking medicines asadvised, non-adherence and limited knowledge of illness,its consequences and therapies [26].

Review Q 3: what individual, service and system factorscontribute to safety among ethnic minority healthcareconsumers?Several factors contributed to the risk of patient safetyevents in health care for ethnic minority patients, al-though their independent and collective contributionwas not clear from work to date. Our narrative thematicsynthesis identified following factors: 1) language profi-ciency; 2) errors associated with formal and informal in-terpretation; 3) misinterpretation of instructions; 4)income and insurance; 5) beliefs about illness and treat-ment; 6) family and friends for safety vigilance; and 7)patient-professional interactions. We found that oftenthese factors were integrated and not readily distin-guished as uniquely individual or service or system levelfactors. For example, issues around language proficiencywere an individual issue in terms of one’s own languageproficiency, but it was also about readiness or feasibilityof accessing a health system without strong proficiencyin a national or native language.

a) Language proficiency



Method/Sample



healthcaresetting

Six Chinese & 11Vietnamese

eligible Chinese andVietnamese Australianswho have never received aHMR manage theirmedicines;b) To what extent they areaware of the existence ofthis servicec) How likely they mightbe to accept and receive aHMR in the future.

effectiveness ofprescribed medications,fear of generic brands,fear of taking too manymedications and a lack ofmedicine informationcontributing to non-adherence and confusion.

• Vietnamese patients,although having someconcerns withmedications did not shownon-adherence to dosingregimen and voice strongrespect for GP.

• Both groups reporteddifficulties locating apharmacist who spoketheir native language,which contributed to anincreased unmet need formedicine information.


In their prospective incident record review study, Diviet al. identified some degree of detectable physical harmoccurred in almost 50% of the LEP identified patients ascompared to 30% harm among English speaking patients[41]. They defined LEP status as inability or limited abil-ity to read, write or understand English that impacts ontheir ability to interact with healthcare professionals[41]. Although communication failure was detected as afactor for more than half of the adverse events occurringin LEP patients, the authors also identified the giving ofquestionable advice, and incorrect/inadequate interpret-ation and assessment of the patient by the health profes-sional as possible causes [41]. In a paediatric setting,Cohen et al. found that Spanish speaking families whoneeded language assistance had a significantly higherrisk of experiencing a serious adverse event [40]. But au-thors also acknowledged that lower socioeconomic sta-tus, lower income level and lack of insurance status mayimpact on their findings [40]. Identifying patients withlimited language proficiency is essential to provide rele-vant interpreting services; however, three studies identi-fied that often there is either an overestimation orincorrect recording of the language data [45, 70, 73]. Inone retrospective record review of adverse or sentinelevents in the US, the authors identified that medical re-cords data relating to language was only entered cor-rectly 30% of the time [73]. In another record reviewstudy conducted in the Netherlands, 30% of patientsidentified as low Dutch proficient, had no mention of alanguage barrier or language proficiency documented intheir medical record [70].

b) Errors associated with formal and informalinterpretation

The review revealed that use of professional interpret-ing services was free in most developed countries. How-ever, their use by healthcare professionals was limitedwith many choosing to use ad hoc interpreters, such ascarers, family members or people other than the quali-fied interpreters, or no interpreters [17, 54, 68, 70]. Intheir qualitative study exploring the role of relatives ofethnic minority patients for patient safety in hospitalcare, van Rosse et al. noted that use of relatives as inter-preters can increase the patient safety risk by inad-equately interpreting information to the patient but canalso decrease the patient safety risk when the use of in-terpreter is not feasible [72]. Relying on patient/carer in-terpretation during the care process is sometimesrequired and this can reduce reliance on professionalservices, but is problematic due to the code of confiden-tiality thus limiting communication [46]. The key risksresulting were poor communication, inadequate patientassessment, poor patient understanding of prescribed

treatment and inadequate warning about clinical risksassociated with treatment [46, 72, 73]. Two studiesexamining use of various types of interpreters and theirimpact on errors of potential clinical consequences werealso included [42, 43]. Flores et al. analysed 13 interviewtranscripts consisting of six trained medical interpretersand seven ad hoc interpreters [42]. They found 396interpreting errors with an average of 31 errors per en-counter. The most common error types were omission,false fluency, substitution, editorialisation and addition[42]. They found that errors with potential clinical con-sequence to be significantly higher when ad hoc inter-preters were used compared to the use of trainedmedical interpreters (77% vs 53%) [42]. However, thisstudy did not discuss if adverse events occurred. In an-other cross-sectional study involving two paediatric hos-pitals, audio taped interpreter encounters (n = 57)revealed that the use of ad hoc or no interpreters was re-lated to double the errors of potential clinical conse-quence when compared to using trained medicalinterpreters [43]. They noted that recency of practicewas linked with less errors than the years of experiencefor the trained interpreters [43].

c) Misinterpretation of instructions

Patient safety events resulting from the misinterpret-ation of medication prescription labels and misunder-standing of discharge instructions were more commonlyreported among ethnic minority patients in nine studies[17, 36, 47, 50, 51, 55, 60, 63, 65]. In their mixed-method study involving 308 patients (203 with LEP),Karliner et al. used principle discharge diagnosis, medi-cation outcomes (category, purpose, combined categoryand purpose) and follow up appointment type asmarkers for understanding discharge instructions [50].They observed that patients with LEP had lower odds ofunderstanding medication category (0.63) and combinedmedication purpose and category after adjusted analysisreflecting some difficulty in understanding discharge in-structions [50]. Masland et al. in their analysis of Califor-nia’s 2007 Health Interview Survey (n = 48,968) foundthat LEP increased the odds of difficulty in understand-ing the prescription instructions three times for CentralAmericans, Mexicans and Koreans and four times forChinese. They also found that low income (OR1.7), loweducation (OR1.6) and recent migration (OR1.5) in-creased the chances of difficulty in understanding pre-scription [55]. While having a bilingual doctor reducesthe odds of difficulty in understanding of prescriptionsfor Mexicans, Koreans and Vietnamese, it does not forChinese and Central Americans [55]. The authors ex-plain that high level of linguistic diversity within theCentral Americans and Chinese may have impact on


truly finding a language concordant bilingual doctor [55].Two studies also identified that health professionals’ self-identified capacity to provide instructions in patients lan-guage can also lead to increased risk of safety eventsthough no quantitative data was available [53, 73].

d) Income and Insurance

Six included studies discussed impact of income or in-surance on patient safety with five studies emergingfrom the US [37, 39, 57, 66, 69, 71]. Coffey et al. andShen et al. in their review using large administrativedataset and PSI as outcome measures noted that the rateof PSIs for low income group and the patients with Me-dicaid was higher than for high income group or thosewith private health insurance [39, 66]. These studiescompared the impact of insurance or income independ-ently. Mix results were obtained when they were studiedtogether with ethnic status demonstrating increased riskfor African Americans. Shen et al. observed that there wasno racial disparities for pressure ulcer among patients withMedicaid, but African Americans with private insurancewere more likely than Caucasians to incur pressure ulcer[66]. Coffey et al. studied the impact of income and racialgroup and noted that African Americans had higher ratefor PSIs than Caucasians in all community income groups[39]. Authors noted a range of factors that may contributeto this relationship such as hospital resources [39, 66]. Insettings with universal health insurance or access such asThe Netherlands, there appeared to be fewer differencesin safety events between ethnic minority and other pa-tients but a lack of studies examined the role of income orprivate health care coverage on safety events outside of USsettings [71].

e) Beliefs about illness and treatment

Suurmond et al. and Masland et al. noted that con-sumers from ethnic minorities have different beliefsabout illness and treatment to that of the health profes-sionals depending on their cultural and religious beliefs[17, 55]. Six other studies discussed the differences inthe beliefs about illness and treatment and its impact onsafety events [12, 26, 33, 38, 52, 55]. These were dis-cussed in the context of medication adherence, compli-ance to treatment recommendations, but no quantitativedata was available to measure the impact on patientsafety events. The impacts observed varied anddepended on population and setting. A systematic re-view examining medicine-related problems among eth-nic minority population in the UK identified that beliefsabout illness and treatment based on religious practicesmay cause safety events such as not taking medication asprescribed [26]. A qualitative study expanding on this

identified that religious practices such as patients fastingfor religious purposes alter their medications by changingthe time or completely stopping it without consultingtheir doctor [33]. In their mixed methods before-afterstudy using focus groups and surveys, Cantarero-Arevaloet al. observed that ethnic minority consumers often feelisolated in a new country due to language and cultural dif-ferences resulting in mistrust with health professionalsand non-compliance with medicine and treatment [38].Two studies discussed interventions, using bilingualworkers from same background to that of the consumersproviding culturally appropriate education program toethnic minorities, to improve medication adherence andimprove knowledge of treatment [38, 52]. A pre- and post-intervention survey of the Korean adults (n = 68) receivingeducation about medication prescriptions by Koreanspeaking pharmacy students demonstrated the adults sig-nificantly increased their understanding of medication di-rections and had improved trust with pharmacists [52].Another mixed method study evaluated culturally compe-tent education provided by bilingual fieldworker from thesame culture and concluded improved knowledge ofmedicine-related problems [38]. However, the sample sizewas small (n = 8) to demonstrate generalisability. Neitherof these interventions demonstrated quantitative impacton patient safety events.

f) Family and friends for safety vigilance

Families and friends were identified in having an im-portant role for safety vigilance of their loved ones intwo studies. Van Rosse et al. observed that patients fromethnic minorities were more often accompanied by fam-ilies or friends compared to Dutch born patients duringhospitalisation and voiced concerns to the health profes-sionals which enhanced their safety [71]. Another quali-tative study of 80 semi structured interviews withconsumers from South Asian or Middle Eastern back-grounds in the UK reported that participant oftenstopped their medications on advice of family or friends,consumed non-prescription medication on advice offamily or friends, and also shared their medicines withfamily members resulting in double dosing for some[33]. van Ross et al. in their study conclude that patientsafety can be enhanced by optimising collaboration withthe family and friends who are willing to take part in thecare process [71]. Goenka, in her literature review, pro-vided one such example of collaboration – Familycentred round (FCR) - in a hospital setting to improvecollaboration with families of LEP patients [45]. How-ever, they did not evaluate the effectiveness of the pro-gram on patient safety.

g) Patient-professional interactions


Ethnic minority patients’ interactions with health pro-fessionals and systems were discussed in seven studieswith focus on bias and lack of communication resultingin inappropriate care with potential for a patient safetyevent [12, 17, 26, 33, 36, 63, 64]. Health professional’spresumption about the desire of ethnic minority con-sumers to engage in their care or their level of under-standing may result in unsafe care. In their prospectiveobservational study of 210 paediatric emergency depart-ment discharges, Samuels-Kalow et al. observed thatwhen health professionals were providing informationregarding pain killers (acetaminophen) to patients, theygave different information to English speaking and Span-ish speaking parents [63]. In their systematic review ofmedicine-related problems in ethnic minority patients inthe UK, Alhomoud et al. noted an underestimation ofpatients desire for information and engagement in deci-sion making by health professionals [26]. In a mixedmethod study using interviews with consumers fromfour different ethnicities (n = 18), authors noted that thelack of communication between various departmentswithin a hospital as well as with community practi-tioners such as general practitioners can impact on caresuch as ceasing a patient’s medicines prescribed by a GPduring hospitalisation [36]. This frequent change appliesto all populations but potentially this is a greater threatto patients from ethnic minorities due to various othercompounding factors, such as greater investment of timerequired to build relationships and engagement withethnic minority consumers [25].

DiscussionOur review findings provide substantial evidence to sug-gest that people from ethnic minorities are vulnerable to ahigher rate of patient safety events in the hospital andcommunity setting compared to the mainstream popula-tion. Specifically, included studies showed that ethnic mi-norities experienced higher incidences of healthcareassociated infections, dosing errors, ADEs and complica-tions resulting from their care [35, 37, 39, 57, 66]. Ethnicminority populations being more likely to experience un-safe health care may compound or contribute to alreadyexisting inequities in health outcomes. Importantly, thisreview also highlights the limited socio-cultural data avail-able in health systems internationally and the implicationsof this for establishing healthcare inequalities.Factors contributing to the increased threat to ethnic

minority populations include socioeconomic factors suchas income, insurance and education; language profi-ciency; health literacy; length of stay in the host country;feeling of alienation and distrust for the health profes-sional, services and systems; and, engagement [38, 39,41, 55, 64, 66]. Included studies mostly studied these fac-tors independently of each other with little discussion of

any relationship between them. In the limited evidenceavailable of this relationship, it was apparent that LEPand health literacy had implications for understandingprescriptions for medication [55]. Health literacy hasbeen explored extensively in relation to poor health out-comes for ethnic minority patients, but there is limitedevidence regarding its role in, and interactions with, fac-tors linked to patient safety events [74]. A conceptualmodel (Fig. 2) has emerged from our review that identi-fies the major factors that heighten the vulnerability ofethnic minority patients to patient safety events. Furtherknowledge regarding the cumulative impact of these fac-tors on patient safety events is required as well as betterunderstanding of their relationship with each other andthe level of impact each factor may have on potential pa-tient safety events.Health systems change towards providing culturally

competent care by hiring more interpreters or using bi-lingual health professionals were commonly cited in thereviewed articles [51, 55, 64]. Yet studies to date havemainly explored organisational and staff cultural compe-tence in the context of improving access to care andcommunication rather than preventing unsafe care spe-cifically [75, 76]. The role of bilingual healthcare staff inpositively addressing language and culture was identifiedin a number of studies [51, 58, 64]. Bilingual staff mayimprove communication and are highly valued by orga-nisations and patients alike as they speak the patients’language and understand their culture context [25, 77].The evidence from the present review suggests that useof interpretation through a range of means is valuable inaddressing some patient safety issues but may also leadsto others.Mobile technologies that can translate for interpretation

are recognised as a potential solution to overcome lan-guage barriers; research indicates ethnic minority con-sumers use this technology [25]. Google Translate, a web-based tool, is available but low translation accuracy ofmedical terminologies has the potential for distress andharm [78]. Current applications such as CALD- Assist (anAustralian application) that uses pre-recorded text wordsand phrases along with pictures and videos for alliedhealth and nursing staff to facilitate communication wheninterpreters are not available or not practical [79] notwith-standing the applications have shown improved satisfac-tion for communication between consumers and healthprofessionals. More research is needed to understand thepatient safety implications of them.The importance of the active participation and engage-

ment of healthcare consumers both in care and studydesign is recognised through this review as contributingto safety outcomes and research quality. The relation-ship between consumer involvement in healthcare andenhanced health outcomes including patient safety is


well-established and reinforced through this review [80].The Australian Commission of Safety and Quality inHealth Care (ACSQHC) identifies consumer engage-ment strategies as central to improved health andhealthcare safety outcomes for consumers [21, 81]. Re-cent studies has also highlighted the role of patient andcarer engagement among ethnic minority populations ascritical for enhanced healthcare [25, 77]. Consumers canact as safety buffer by identifying when the care is notadequate or unsafe [82]. Included studies in the presentreview reflect this demonstrating that family membersand carers can contribute to safety by voicing theirconcerns to health professionals and advocating for thepatient [71].

ImplicationsPolicy organisations focused to improve health carequality internationally identify ethnic minorities as a pri-ority group but specific guidance about reducing patientsafety events is limited [83, 84]. Key implications fromthis review relate to the vital role of family and carers insupporting safe care. Despite recognition of the need forenhanced consumer engagement among ethnic minorityconsumers, few service and system level support struc-tures exist to support engagement with patients or theirfamily members [14, 26]. Strategies utilised by the widerpatient population, such as checklists or consumertoolkits designed to assist in asking health professionalsquestions and raising concerns during their care, areunder-utilised in ethnic minority populations [81]. En-gagement strategies that take into account the nuancedifferences between ethnic minority consumers are lack-ing and involving ethnic minority consumers can helpdevelop relevant engagement strategies [25]. Co-designapproaches to adapt and develop suitable engagementstrategies may be of value to address this gap. A key

consideration is how to ensure that approaches to en-hance family and carer engagement are explored.We also found deficiencies in routinely collected

healthcare data. Our synthesis of the included studiesshowed insufficient data regarding factors, that collect-ively create an individual’s ethnic profile, with most datasets relying on information about country of birth, lan-guage spoken and in some instances race to classify eth-nic minority individuals. Classifications such as ‘Asian’or ‘Caucasian’ can be deemed to be homogenous andfails to capture the range of different ethnic minoritiesincluded under either of the terms [85]. Given the evi-dence of multiple patient safety threats for ethnic minor-ity groups, establishing an individual’s ethnic profile ingreater detail is essential so as to fully understand if par-ticular patient safety issues are in play and to develop fo-cused interventions.Several authors commented on the superficial identifi-

cation of ethnic minority patients and recommendedsystems be strengthened to allow complete identificationof ethnic minorities [45, 70]. There is a need to registermore specific socio-cultural data. It is recognised thatnuanced differences exist between various ethnic minor-ity groups [86] and collection of superficial indicators toidentify ethnic minority population may not provide afull picture of cultural and social factors shaping prac-tices and understanding of health of a particular ethnicminority group. The Australian Bureau of Statistics(ABS) recommends that diverse variables be used toidentify consumers from different ethnic minorities [87].Health services often only collect data relating to lan-guage, country and interpreter use [87, 88]. In the UScontext, Wilson-Stronks et al. recommended level ofhealth literacy, cultural needs, dietary needs and socio-economic variables be collected along with language andreligion [85]. Similarly, Lopez et al. recommended an au-tomated standard system -designed in consultation with

Fig. 2 Conceptual model for vulnerability to safety events for ethnic minority consumers


ethnic minority consumers - for collecting data concern-ing ethnic minority and language proficiency [89]. Theysaw this as a way to reduce the disparity in quality andsafety of health care [89].

LimitationsThis review has some limitations. The diversity of the defi-nitions used to determine the ethnic minority populationshaped the findings. For example, in United States, ethnicminorities were primarily defined based on the race or thefirst language, with many studies focused to differentialsbetween African Americans, Hispanic and Caucasian pop-ulations [57, 66]. This differentiation resulted in moststudies from the US using large data to examine the im-pact of insurance or income to the disparity in safetyevents [39, 66]. This also led to focus on language, espe-cially in context of Hispanic population, as a factor for thedisparity [40]. In addition, use of terms such as ‘Asian’ ap-peared to refer to two different population groups; in USand Australia this primarily referred to people from Chinaor far eastern Asian countries, but in the UK this wasoften used in the context of people from India/Pakistan[90]. We limited our search to Organisation for EconomicCo-operation and Development (OECD) countries as theethnic minority groups are considered more comparableand thus our findings are not generalisable beyond theOECD countries. The review sought only published workswhich may have led to the omission of other relevantworks that were not published. Grey literature includinggovernment reports were not included and this may haveled to the omission of relevant information. The inclusionof five databases along with the reference lists of includedarticles provided a broad and varied range of data sourcesto identify relevant literature. Publication bias may alsohad impact on included studies with non-published nega-tive findings omitted [91].

ConclusionOur findings indicate substantial disparity in safetyevents occurring between ethnic minority and main-stream populations. The nature of patient safety eventsto which ethnic minority populations are exposed to isdependent on the setting and minority population. Pa-tient safety appears to be linked with the availability anduse of interpreters, degree of engagement with familyand carers, and the availability of systemic processes toovercome language and socio-economic barriers. En-hanced socio-cultural data across health systems is crit-ical. Knowledge of the factors that contribute andcompound to create safety for ethnic minority groups,and of the individual differences between various ethnicminority groups in terms of their healthcare safety islimited. Engaging ethnic minority consumers in the de-sign of interventions to enhance safety is key.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12939-020-01223-2.

Additional file 1: Supplementary file 1 for search strategy.

Additional file 2: Supplementary file 2 for quality assessment criteria.

AbbreviationABS: Australian Bureau of Statistics; ACSQHC: Australian Commission of Safetyand Quality in Health Care; ADE: Adverse drug events; CALD: Culturally andlinguistically diverse; FCR: Family centred round; LEP: Low English proficiency;MPSMS: Medication Patient Safety Monitoring System; OECD: Organisationfor Economic Co-operation and Development; PSI: Patient Safety Incident;UK: United Kingdom; US: United States

AcknowledgementsNot applicable

Authors’ contributionsAC and RH conceptualised the study. SM completed the database search. ACand RH completed the screening of the articles. AC completed writing themanuscript. RH, MW, EM. HS, RLW, DL, ML and SM provided feedback duringanalysis and reporting of the findings. All authors reviewed and agreed on thefinal version for submission. This review is also part of the AC’s doctoral thesis.

FundingThis project is funded by NHMRC project grant 1049703 administered by theUniversity of Sydney.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.Availability of data and materialsData available on request from the authors.

Competing interestsAuthors declare no competing interest.

Author details1School of Public Health and Community Medicine, University of New SouthWales, Sydney 2052, NSW, Australia. 2School of Public Health, University ofSydney, Sydney 2006, NSW, Australia. 3School of Nursing and Midwifery,Centre for Quality and Patient Safety Research, Institute for HealthTransformation, Deakin University, Melbourne 3025, VIC, Australia.4Multicultural Health, Western Sydney Local Health District, Westmead 2145,NSW, Australia. 5Hunter New England Health Libraries, Hunter New EnglandLocal Health District, Tamworth 2310, NSW, Australia.

Received: 20 February 2020 Accepted: 16 June 2020

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