literature review on language barriers

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.35(2); 2020 Mar

Implications of Language Barriers for Healthcare: A Systematic Review

Hilal al shamsi.

1 Director of Planning and Studies, Directorate General of Planning and Studies, Ministry of Health, Al Buraimi, Oman

Abdullah G. Almutairi

2 Director of Tumair Hospital, Ministry of Health, Riyadh, Saudi Arabia

Sulaiman Al Mashrafi

3 Directorate General of Planning and Studies, Department of Health Information and Statistics, Ministry of Health, Muscat, Oman

Talib Al Kalbani

4 Director of Pharmaceutical Care and Medical Stores, Directorate General of Health Services, Ministry of Health, Al Buraimi, Oman

Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high- quality healthcare and maintaining patient safety. To address these challenges, many larger healthcare institutions offer interpreter services to improve healthcare access, patient satisfaction, and communication. However, these services increase the cost and duration of treatment. The purpose of this review is to investigate the impact of language barriers on healthcare and to suggest solutions to address the challenges.

We identified published studies on the implications of language barriers in healthcare using two databases: PubMed and Medline. We included 14 studies that met the selection criteria. These studies were conducted in various countries, both developed and developing, though most came from the US. The 14 studies included 300 918 total participants, with participation in each study ranging from 21 to 22 353 people.

We found that language barriers in healthcare lead to miscommunication between the medical professional and patient, reducing both parties’ satisfaction and decreasing the quality of healthcare delivery and patient safety. In addition, the review found that interpreter services contribute indirectly to increased cost and the length of treatment visits. One study reported the implementation of online translation tools such as Google Translate and MediBabble in hospitals, which increased the satisfaction of both medical providers and patients (to 92%) and improved the quality of healthcare delivery and patient safety. Language barriers are responsible for reducing the satisfaction of medical providers and patients, as well as the quality of healthcare delivery and patient safety. Many healthcare institutions use interpreter services that increase the cost and length of treatment visits.

Conclusions

The results of our review suggest that implementing online translation tools such as Google Translate and MediBabble may improve the quality of healthcare and the level of satisfaction among both medical providers and patients.

Introduction

Language barriers have a major impact on the cost and quality of healthcare. They commonly occur between healthcare providers and patients when the two groups do not share a native language. 1 Regardless of language barriers, healthcare providers are required to deliver high-quality healthcare that adheres to the principles of human rights and equity to all their patients. 2

Health disparities such as unequal treatment related to language barriers are associated with unequal access to healthcare and unequal health outcomes. 3 For instance, a recent study demonstrated that patients who do not speak the local language are disadvantaged in terms of access to healthcare services. 4 Similarly, several studies have shown that patients who face language barriers have poorer health outcomes compared with patients who speak the local language. 5 , 6

Growing evidence documents the fact that language barriers indirectly impact the quality of the healthcare that patients receive. Language barriers contribute to reducing both patient and medical provider satisfaction, as well as communication between medical providers and patients. Patients who face language barriers are more likely to consume more healthcare services 2 and experience more adverse events. 7 A recent study conducted in six hospitals in the US found that adverse events occurred more frequently among patients with limited proficiency in English than among those who were proficient in English.

This review investigates the impact of language barriers on healthcare and suggests solutions to address the challenges.

We identified studies of the impact of language barriers on the delivery of healthcare by searching the PubMed and Medline databases using the keywords: ‘language barriers,’ ‘satisfaction,’ ‘healthcare,’ ‘limited English proficiency,’ ‘quality of care,’ ‘communication,’ and ‘access to health services’.

This review includes studies that address the impact of language barriers on the delivery of healthcare. It excludes studies into the impacts of communication barriers other than language barriers on the delivery of healthcare, studies that were not primarily conducted in healthcare organizations, and non-peer-reviewed articles. The search strategy was limited to articles published from 2000 to 2019 to find the most recent literature on the topic.

The extracted data are summarized in two tables. Table 1 outlines the general characteristics of the studies, including the country in which the study was done, the total number of organizations in which the sample was collected, the type of organization that conducted the study, the study type, the data collection method, the sample size, and the response rate. Table 2 presents the implication of language barriers on the delivery of healthcare in each study in the review.

*MOH: Ministry of Health; NA: not applicable; NR: not recorded.

Figure 1 shows the researcher’s method of selecting eligible studies for this review. Initially, the researcher’s search of the PubMed and Medline databases returned 2569 articles. After removing the duplicate articles, 1211 remained. Next, the researcher excluded the articles that were not mainly about language barriers (n = 605) and the non-peer-reviewed articles (n = 532). Then the researcher excluded those studies that were not primarily conducted in healthcare organizations (n = 60), leaving 14 articles to be included in this systematic review.

The process of selecting the included 14 studies in this review.

Table 1 presents a summary of the general characteristics of the 14 studies arranged by the authors’ names. Nine studies used a cross-sectional design, two used a prospective design, two used qualitative research, and one was a report. Five studies collected data from an interview survey, three used questionnaires, one used both an interview survey and questionnaires, three used hospital databases, and two used telephone and mail surveys. Five of the studies were conducted in the US, two in Saudi Arabia, two in Switzerland, and one each in Canada, Germany, England, Norway, and South Africa. The total number of participants in the 14 studies was 300 918, with the number of participants in each study ranging from 21 to 22 353.

Table 2 presents the most important findings of the 14 studies in this review. Seven of the studies focused on language barriers and patient satisfaction, two on the impact of language barriers on healthcare provider satisfaction, one on the impact of language barriers on both healthcare providers and patient satisfaction, two on the cost of interpretation services, one on the quality of interpretation services, and one on online translation tools. The findings of studies can be divided into three categories: the impact of language barriers on medical providers (such as physicians and nurses), patients, and the cost and quality of healthcare services.

Communication between patients and medical providers is at the heart of effective healthcare. In Pytel, 17 94.3% of nurses reported that it was very important for their work environment and communication to understand the language of their patients. Physicians also have difficulty understanding patients who do not speak their language, leading to wrong diagnosis and medications. 18 In Norway, medical providers reported that they had trouble understanding between 36% and 43% of the patients who do not speak the local language, necessitating interpreters. 15 Indeed, 37% of physicians indicated that they felt that patients hide some information because of language barriers. 15 In addition, all South African nurses in Saudi Arabia had difficulty communicating with patients and their family members, as well as nurses from other countries, because of language barriers. 19

Language barriers have negative implications for the delivery of healthcare and patient satisfaction. One study showed that among patients who received treatment from nurses who did not speak the local language, 30% had difficulty understanding medical instructions, 30% had a problem with the reliability of information, and 50% believed that the language barrier contributed to errors. 10 Other studies found that among patients who did not speak the local language, 49% had trouble understanding a medical situation, 34.7% were confused about how to use medication, 41.8% had trouble understanding a label on medication, 15.8% had a bad reaction to medication due to a problem understanding their healthcare provider’s instructions, 20 66.7% faced a barrier when accessing healthcare, and 20% did not seek healthcare services if these were not readily available for fear of not understanding their healthcare provider. 14 Furthermore, many patients with limited local language proficiency experienced adverse health events that resulted in detectable physical harm (49.1% of patients) or moderate temporary harm (46.8%) or experienced some failure in communication with medical providers (52.4%). 5 Patients with limited local language proficiency are also likely to miss medical appointments and have difficulties arranging appointments due to the language barrier. 9 Therefore, these patients have a poor level of satisfaction with their healthcare. 14 , 18

To increase patient satisfaction with healthcare, it is necessary to provide interpreter services. Two studies pointed out that medical providers needed interpreter services for 43.2% of their patients, and 21–76% of medical providers stated they had poor access to these services. 12 , 15 Moreover, 70.7% of limited English proficiency patients (LEPPs) reported limited availability of interpreter services, 13 , 14 and 26.4% reported that there were no interpreters in their healthcare institutions. 2 LEPPs also indirectly raise the cost of health services when they use interpreter services. 12 LEPPs who used interpreter services received more inpatient services and attended more office visits than those who did not. 11 The authors of this study estimated that interpreter services for Medicaid recipients at about $4.7 million annually. Some healthcare organizations use online translation tools such as Google Translate and MediBabble to address the challenges of language barriers. These tools are free and easy to access, and they contribute to improving healthcare delivery, patient safety, and increased (up to 92%) the satisfaction of both medical professionals and patients. 8

This review investigates the impact of language barriers on the delivery of healthcare and identifies possible solutions to the challenges posed by these language barriers. The first impact of language barriers is miscommunication between medical providers (physicians and nurses) and patients [ Table 2 ]. This miscommunication contributes to a reduction in the satisfaction of both medical providers and patients, the quality of healthcare delivery, and patient safety. The second impact is an increase in indirect healthcare costs. The final impact is the application of online translation tools to healthcare organizations, which improves the quality of healthcare delivery and patient safety and increases the satisfaction of both medical professionals and patients.

Language barriers are a key cause of miscommunication between medical providers and patients, and negatively affect the quality of healthcare services and patient satisfaction. Hospital medical professionals perceive language barriers to be a source of workplace stress and an impediment to the delivery of high-quality healthcare. 21 Much evidence shows a significant association between workplace stress and lower satisfaction among medical providers. 22 - 24 In addition, studies indicate that language barriers contribute to medical professionals’ incomplete understanding of patients’ situations, delayed treatment or misdiagnoses, poor patient assessment and incomplete prescribed treatment. 14 , 25

We also found that patients who do not speak the local language will have less satisfaction with their healthcare and less access to usual sources of healthcare. Even when patients with language barriers have access to healthcare, they have decreased satisfaction with that healthcare, decreased understanding of their diagnoses, and increased medication complications. 25 , 26 A study conducted in Saudi Arabia showed that 25% of foreign patients reported that they had difficulty communicating with medical professionals and decreased satisfaction with their healthcare; 20% of medical professionals reported that health outcomes (i.e., healthcare errors, understanding patient needs, feeling satisfaction, and trust in nursing care needs) were always affected by language barriers. 27 Interpreter services are necessary to solve the problem of language barriers in healthcare institutions and to increase the satisfaction of both medical professionals and patients.

To overcome language barriers, some healthcare institutions provide interpreter services; however, these services pose critical challenges in terms of access and financial burden. Previous studies have shown that most healthcare institutions have poor access to interpreter services or no services at all. 12 , 14 The use of interpreter services contributes to increased patient satisfaction and improved patient care among patients with language barriers. 28 Interpreter services have a significant association with increased physician visits, prescription drugs by physicians, and receipt of preventative services among patients. 29 However, providing interpreter services also increases the length and cost of physician visits.

MediBabble is an application created by medical students at the University of California, San Francisco, and released in 2011. Using advanced voice recognition software, it offers translations for thousands of medical instructions, as well as the questions for a standard medical history. 30 , 31 The application contains thousands of instructions and translated questions, organized by symptom. Most questions can be answered with ‘yes’ or ‘no’ gestures. 32 MediBabble can be used online or offline, and it allows physicians to take patient histories and make diagnoses when a language barrier exists. 32 However, the application translates only six languages: English, Spanish, Russian, Cantonese, Haitian Creole, and Mandarin. 32

A case study showed that medical professionals and patients were highly satisfied with MediBabble; they reported that the application was fast and easy in terms of translating and collecting information. 33 In a study done in Canada, MediBabble was used as one strategy to improve the delivery of healthcare for resettled Syrian refugees. It allowed medical professionals to take the refugees’ histories and also make diagnoses. 30 In brief, MediBabble shows success as a medical translator. Using both interpreter services and online translation tools may offer more opportunities to improve healthcare delivery and patient safety.

This review has some limitations. First, there are few existing studies on the application of online translation tools in healthcare to address the problem of language barriers. Second, there are few studies evaluating the challenges of language barriers in private healthcare organizations. The impact of language barriers must be evaluated in both the public and the private sectors to address this problem.

This review also has several strengths. First, studies included in the review were conducted in both developing and developed countries. Second, the response rate was 100% in six of the studies. Third, the studies focused on various aspects of language barriers in healthcare, which helped the researchers to evaluate the challenges from multiple angles and determine solutions.

Language barriers can make the delivery of high-quality healthcare very challenging. They have a negative impact on the quality of healthcare, patient safety, and the satisfaction of medical professionals and patients. While some health organizations provide interpreter services to address these problems, these services indirectly increase the cost of health services and increase the length of treatment visits. Online translation tools such as Google Translate and MediBabble present possible solutions for overcoming these challenges. Further studies on the implications of language barriers and the effectiveness of online translation tools are recommended. Furthermore, new updates with more medical phrases for Google Translate and with more languages included for MediBabble application are recommended.

The authors declared no conflicts of interest.

Advertisement

Conceptualizing the Pathways and Processes Between Language Barriers and Health Disparities: Review, Synthesis, and Extension

• Original Paper
• Published: 12 December 2015
• Volume 19 , pages 215–224, ( 2017 )

Cite this article

• Sachiko Terui 1  

4623 Accesses

30 Citations

4 Altmetric

Explore all metrics

While many may view language barriers in healthcare settings (LBHS) as a simple, practical problem, they present unique challenges to theoretical development and practice implications in healthcare delivery, especially when one considers the implications and impacts of specific contextual factors. By exploring the differences of contextual factors in the US and Japan, this review explores and highlights how such differences may entail different impacts on patients’ quality of care and require different solutions. I conduct narrative review through library database, Google Scholar, and CiNii (a Japanese library database) with multiple search terms, including language barriers, healthcare, medical interpreter, and immigrant. I first present a diagram to show the pathways and process between language barriers and health disparities, using the literature reported in the US. Then, I examined the literature reported in Japan and discuss the needs for re-conceptualizing LBHS. The implications for future research will be discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

Elana Curtis, Rhys Jones, … Papaarangi Reid

Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia

O. Pearson, K. Schwartzkopff, … on behalf of the Leadership Group guiding the Centre for Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE)

The ABC of systematic literature review: the basic methodological guidance for beginners

Hayrol Azril Mohamed Shaffril, Samsul Farid Samsuddin & Asnarulkhadi Abu Samah

Karliner LS, Ma L, Hofmann M, Kerlikowske K. Language barriers, location of care, and delays in follow-up of abnormal mammograms. Med Care. 2012;50:171–8.

Article   PubMed   PubMed Central   Google Scholar  

Schwei RJ, Del Pozo S, Agger-Gupta N, Alvarado-Little W, Bagchi A, Chen AH, et al. Changes in research on language barriers in health care since 2003: a cross-sectional review study. Int J Nurs Stud. 2015. doi: 10.1016/j.ijnurstu.2015.03.001 .

PubMed Central   Google Scholar  

Timmins CL. The impact of language barriers on the health care of Latinos in the United States: a review of the literature and guidelines for practice. J Midwifery Women’s Health. 2002;47:80–96.

Article   Google Scholar  

Jacobs E, Chen AH, Karliner LS, Agger-Gupta N, Mutha S. The need for more research on language barriers in health care: a proposed research agenda. Milbank Q. 2006;84:111–33.

Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. JGIM. 2009;24:256–62.

Article   PubMed   Google Scholar  

Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. JGIM. 1999;14:82–7.

Article   CAS   PubMed   Google Scholar  

Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355:229–31.

Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19:60–7.

Diamond LC, Jacobs EA. Let’s not contribute to disparities: the best methods for teaching clinicians how to overcome language barriers to health care. JGIM. 2010;25:189–93.

Article   PubMed Central   Google Scholar  

Fernandez A, Schillinger D, Warton EM, Adler N, Moffet H, Schenker Y, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). JGIM. 2011;26:170–6.

Sentell T, Braun KL, Davis J, Davis T. Colorectal cancer screening: low health literacy and limited English proficiency among Asians and Whites in California. J Health Commun. 2013;18:242–55.

Butow P, Bell M, Goldstein D, Sze M, Aldridge L, Abdo S, et al. Grappling with cultural differences; communication between oncologists and immigrant cancer patients with and without interpreters. Patient Educ Counsel. 2011;84:398–405.

Barber BR. Jihad vs. McWorld. New York: The Random House Publishing Group; 1995.

Google Scholar  

Hofstede G. Culture’s consequences: international differences in work-related values. Beverly Hills: Sage; 1980.

Akabayashi A, Fetters MD, Elwyn TS. Family consent, communication, and advance directives for cancer disclosure: a Japanese case and discussion. J Med Ethics. 1999;25:296–301.

Article   CAS   PubMed   PubMed Central   Google Scholar  

De Jong G, Steinmetz M. Receptivity attitudes and the occupational attainment of male and female immigrant workers. Popul Res Policy Rev. 2004;23:91–116.

Prins E, Toso BW. Receptivity toward immigrants in rural Pennsylvania: perceptions of adult English as second language providers. Rural Sociol. 2012;77:435–61.

Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropr Med. 2006;5:101–17.

Baumeister RF, Leary MR. Writing narrative literature reviews. Rev Gener Psychol. 1997;1:311–20.

Gregg J, Saha S. Communicative competence: a framework for understanding language barriers in health care. JGIM. 2007;22:368–70.

Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74:295–301.

Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med. 2000;51:1611–25.

Ndiaye K, Krieger JL, Warren JR, Hecht ML. Communication and health disparity. In: Thompson TL, Parrott R, Nussbaum JF, editors. The Routledge handbook of health communication. 2nd ed. New York, NY: Routledge; 2011. p. 469–81.

Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. London: University of California Press; 1980.

Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31:S19–26.

Institute of Medicine. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. Institute of Medicine; 2002.

Piette JD, Bibbins-Domingo K, Schillinger D. Health care discrimination, processes of care, and diabetes patients’ health status. Patient Educ Couns. 2006;60:41–8.

Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32:20–47.

Bradac JJ, Giles H. Language and social psychology: conceptual niceties, complexities, curiosities, monstrosities, and how it all works. In: Fitch KL, Sanders RE, editors. Handbook of language and social interaction. Mahwah, NJ: Lawrence Erlbaum Associates; 2005. p. 201–30.

Stuber J, Meyer I, Link B. Stigma, prejudice, discrimination and health. Soc Sci Med. 2008;67:351–7.

Lambert WE, Hodgson RC, Gardner RC, Fillenbaum S. Evaluational reactions to spoken languages. J Abnorm Soc Psychol. 1964;60:44–51.

Clark R, Anderson NB, Clark VR, Williams DR. Racism as a stressor for African Americans: a biopsychosocial model. Am Psychol. 1999;54:805.

Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall; 1963.

Thomas SB, Fine MJ, Ibrahim SA. Health disparities: the importance of culture and health communication. Am J Public Health. 2004;94:2050.

Youdelman MK. The medical tongue: U.S. laws and policies on language access. Health Aff. 2008;27:424–33.

DeCamp LR, Kieffer E, Zickafoose JS, DeMonner S, Valbuena F, Davis MM, et al. The voices of limited English proficiency Latina mothers on pediatric primary care: lessons for the medical home. Matern Child Health J. 2013;17:95–109.

Paasche-Orlow MK, Wilson EAH, McCormack L. The evolving field of health literacy research. J Health Commun. 2010;15:5–8.

Kuo DZ, O’Connor KG, Flores G, Minkovitz CS. Pediatricians’ use of language services for families with limited English proficiency. Pediatrics. 2007;119:e920–7.

Jang M, Lee E, Woo K. Income, language, and citizenship status: factors affecting the health care access and utilization of Chinese Americans. Health Soc Work. 1998;23:136–45.

Feinberg E, Swartz K, Zaslavsky A, Gardner J, Walker D. Language proficiency and the enrollment of Medicaid-eligible children in publicly funded health insurance programs. Matern Child Health J. 2002;6:5–18.

Conrad P, Barker KK. The social construction of illness: key insights and policy implications. J Health Soc Behav. 2010;51:S67–79.

Ngo-Metzger Q, Sorkin DH, Phillips RS. Healthcare experiences of limited english-proficient asian american patients: a cross-sectional mail survey. Patient. 2009;2:113–20.

Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language barriers in medicine in the United States. JAMA. 1995;273:724–8.

Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. JGIM. 2005;20:800–6.

John-Baptiste A, Naglie G, Tomlinson G, Alibhai SMH, Etchells E, Cheung A, et al. The effect of English language proficiency on length of stay and in-hospital mortality. JGIM. 2004;19:221–8.

Kravitz RL, Helms LJ, Azari R, Antonius D, Melnikow J. Comparing the use of physician time and health care resources among patients speaking English, Spanish, and Russian. Med Care. 2000;38:728–38.

Bernstein J, Bernstein E, Dave A, Hardt E, James T, Linden J, et al. Trained medical interpreters in the emergency department: effects on services, subsequent charges, and follow-up. J Immigr Health. 2002;4:171–6.

Sarver J, Baker D. Effect of language barriers on follow-up appointments after an emergency department visit. JGIM. 2000;15:256–64.

Goldenberg M. Defining, “quality of care” persuasively. Theor Med Bioeth. 2012;33:243–61.

Mutchler J, Bacigalupe G, Coppin A, Gottlieb A. Language barriers surrounding medication use among older Latinos. J Cross-Cult Gerontol. 2007;22:101–14.

Fernandez A, Schillinger D, Grumbach K, Rosenthal A, Stewart A, Wang F, et al. Physician language ability and cultural competence. JGIM. 2004;19:167–74.

Diamond LC, Reuland DS. Describing physician language fluency: deconstructing medical Spanish. JAMA. 2009;301:426–8.

Andrulis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav. 2007;31:s122–33.

Messias DKH, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters. ANS Adv Nurs Sci. 2009;32:128–43.

Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA. 1996;275:783–8.

Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42:727–54.

Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med. 2012;60:545–53.

Drennan G, Swartz L. The paradoxical use of interpreting in psychiatry. Soc Sci Med. 2002;54:1853–66.

Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62:255–99.

Fagan MJ, Diaz JA, Reinert SE, Sciamanna CN, Fagan DM. Impact of interpretation method on clinic visit length. JGIM. 2003;18:634–8.

Abbe M, Simon C, Angiolillo A, Ruccione K, Kodish ED. A survey of language barriers from the perspective of pediatric oncologists, interpreters, and parents. Pediatr Blood Cancer. 2006;47:819–24.

Ginde A, Clark S, Camargo C Jr. Language barriers among patients in Boston emergency departments: use of medical interpreters after passage of interpreter legislation. J Immigr Minor Health. 2009;11:527–30.

Jacobs E. A better measure of patients’ need for interpreter services. JGIM. 2008;23:1724–5.

Derose KP, Hays RD, McCaffrey DF, Baker DW. Does physician gender affect satisfaction of men and women visiting the emergency department? JGIM. 2001;16:218–26.

O’Leary SCB, Federico S, Hampers LC. The truth about language barriers: one residency program’s experience. Pediatrics. 2003;111:569.

Yawman D, McIntosh S, Fernandez D, Auinger P, Allan M, Weitzman M. The use of Spanish by medical students and residents at one university hospital. Acad Med. 2006;81:468–73.

Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. JGIM. 2007;22:294–9.

Andres E, Wynia M, Regenstein M, Maul L. Should I call an interpreter? How do physicians with second language skills decide? J Health Care Poor Underserved. 2013;24:525–39.

Hsieh E. Not just “getting by”: factors influencing providers’ choice of interpreters. JGIM. 2015;30:75–82.

Rosenberg E, Seller R, Leanza Y. Through interpreters’ eyes: comparing roles of professional and family interpreters. Patient Educ Couns. 2008;70:87–93.

Karliner LS, Auerbach A, Napoles A, Schillinger D, Nickleach D, Perez-Stable EJ. Language barriers and understanding of hospital discharge instructions. Med Care. 2012;50:283–9.

Leyva M, Sharif I, Ozuah PO. Health literacy among Spanish-speaking Latino parents with limited English proficiency. Ambul Pediatr. 2005;5:56–9.

Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20:800–6.

Xu KT, Rojas-Fernandez CH. Ancillary community pharmacy services provided to older people in a largely rural and ethnically diverse region: a survey of consumers in West Texas. J Rural Health. 2003;19:79–86.

Westberg SM, Sorensen TD. Pharmacy-related health disparities experienced by non-English-speaking patients: impact of pharmaceutical care. J Am Pharm Assoc. 2005;45:48–54.

Sleath B. Pharmacists’ experiences in and perceptions toward serving the needs of Spanish-speaking patients in North Carolina community pharmacies. J Pharm Teach. 2002;9:77–91.

Muzyk AJ, Muzyk TL, Barnett CW. Counseling Spanish-speaking patients: Atlanta pharmacists’ cultural sensitivity, use of language-assistance services, and attitudes. J Am Pharm Assoc. 2003;44:366–74.

Ohtsuki S. Japanese views over the increase in foreigners: using JGSS-2003 data [Japanese]. 社会学論考. 2007;28:1–25.

Terasawa T. 英語以外の異言語に対する「日本人」の態度の社会統計的分析 [Japanese]. 東京大学大学院総合文化研究科言語情報科学専攻. 2014;3:91–107.

Takahashi M. The role of interpreters: from the perspectives of community interpreters [Japanese]. Tokyo University of Foreign Studies: Center for Multilingual Multicultural Education and Research; 2009, p. 50–62.

Iida N. The present condition and problems of community interpreters involved in the support system for returnees from China: a study of interpreter roles [Japanese]. 立命館人間科学研究. 2010;21:75–88.

Okubo T. The national health insurance program and illegal immigrants [Japanese]. 社会研論集. 2004;4:141–53.

Ueda A, Ogihara A, Yamaji M, Mitani H. Fact-finding survey on medical information for foreign residents on the web sites of local governments in Japan [Japanese]. Bull Soc Med. 2011;29:63–71.

Kawauchi K. Problems of medical interpreters in Japan [Japanese]. J Aomori Univ Health Welf. 2011;12:33–40.

Wakimoto T, Chisaki M, Uchida K. The perspectives of medical treatment provided to foreign individuals: the role of medical interpretors [Japanese]. J Pediatr Pract. 2013;76:971–5.

Hasegawa T, Takeda C, Tsukida K, Shirakawa K. A study of nursing care for foreigners in Japan [Japanese]. Fukui Med Res J. 2002;3:49–55.

Ministry of Justice. Statistics of foreign residents. 2014.

Maeno M, Enomoto N, Maeno R, Tamaki Y, Tanakamaru H, Fujihara A. The problem of foreign language translation and supporting for foreigners in clinics accepting foreigners [Japanese] 研究紀要. 2010:13–26.

Nakagawa K, Takuwa N. A study on the present status and prospect on medical care for foreign patients in Ishikawa Prefecture: based on a questionnaire survey for registered medical institutes for foreigners [Japanese]. Ishikawa J Nursing. 2012;9:23–32.

Non Profit Organization: Advanced Medical Promotion Organization. Large hospitals in Tokyo: thirty percent indicated the difficulty to accept patients with language barriers [Japanese]. 特定非営利活動団体 先端医療推進機構; 2013.

Park J-G. Foreign language edition home page: Chica city administration home page [Japanese]. 東京情報大学研究論集. 2007;10:11–20.

Abe Y. Necessity for community interpreters to manage mental illness [Japanese]. Tokyo University of Foreign Studies: Center for Multilingual Multicultural Education and Research. 2013, p. 105–113.

Arai K, Sasaki A, Sato C. 外国人妊産婦に対する産科病棟の対応 [Japanese]. 助産雑誌. 2006;60:355–60.

Miyabe M, Yoshino T, Shigeno A. Development of a multilngual medical reception support system based on parallel texts for foreign patients [Japanese]. 電子情報通信学会論文誌. 2009;J92-D:708–18.

Foundation of Global Health Care. Certification for bilingual medical staff (CBMS). 2014.

Iida N. The present condition and problems of medical interpreters for the foreigners living in Japan and visiting Japan [Japanese]. 立命館人間科学研究. 2011;23:47–57.

Usui S. Foreign residents’ experiences in the Japanese health care system and evaluation of their satisfaction [Japanese]: Tokyo Metropolitan University; 2013.

Schenker Y, Karter AJ, Schillinger D, Warton EM, Adler NE, Moffet HH, et al. The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: The DISTANCE study. Patient Educ Couns. 2010;81:222–8.

Kim KI, Park H-J, Suzuki N. Reward allocations in the United States, Japan, and Korea: a comparison of individualistic and collectivistic cultures. Acad Manag J. 1990;33:188–98.

Brown P, Levinson SC. Politeness: some universals in language usage. Cambridge: Cambridge University Press; 1987.

Akechi T, Miyashita M, Morita T, Okuyama T, Sakamoto M, Sagawa R, et al. Good death in elderly adults with cancer in Japan based on perspectives of the general population. J Am Geriatr Soc. 2012;60:271–6.

Download references

Author information

Authors and affiliations.

Department of Communication, University of Oklahoma, 610 Elm Ave. #211, Norman, OK, 73019, USA

Sachiko Terui

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sachiko Terui .

Rights and permissions

Reprints and permissions

About this article

Terui, S. Conceptualizing the Pathways and Processes Between Language Barriers and Health Disparities: Review, Synthesis, and Extension. J Immigrant Minority Health 19 , 215–224 (2017). https://doi.org/10.1007/s10903-015-0322-x

Download citation

Published : 12 December 2015

Issue Date : February 2017

DOI : https://doi.org/10.1007/s10903-015-0322-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Language barriers
• The United States
• Find a journal
• Publish with us
• Track your research

Implications of Language Barriers for Healthcare: A Systematic Review

Affiliations.

• 1 Director of Planning and Studies, Directorate General of Planning and Studies, Ministry of Health, Al Buraimi, Oman.
• 2 Director of Tumair Hospital, Ministry of Health, Riyadh, Saudi Arabia.
• 3 Directorate General of Planning and Studies, Department of Health Information and Statistics, Ministry of Health, Muscat, Oman.
• 4 Director of Pharmaceutical Care and Medical Stores, Directorate General of Health Services, Ministry of Health, Al Buraimi, Oman.
• PMID: 32411417
• PMCID: PMC7201401
• DOI: 10.5001/omj.2020.40

Objectives: Language barriers pose challenges in terms of achieving high levels of satisfaction among medical professionals and patients, providing high- quality healthcare and maintaining patient safety. To address these challenges, many larger healthcare institutions offer interpreter services to improve healthcare access, patient satisfaction, and communication. However, these services increase the cost and duration of treatment. The purpose of this review is to investigate the impact of language barriers on healthcare and to suggest solutions to address the challenges.

Methods: We identified published studies on the implications of language barriers in healthcare using two databases: PubMed and Medline. We included 14 studies that met the selection criteria. These studies were conducted in various countries, both developed and developing, though most came from the US. The 14 studies included 300 918 total participants, with participation in each study ranging from 21 to 22 353 people.

Results: We found that language barriers in healthcare lead to miscommunication between the medical professional and patient, reducing both parties' satisfaction and decreasing the quality of healthcare delivery and patient safety. In addition, the review found that interpreter services contribute indirectly to increased cost and the length of treatment visits. One study reported the implementation of online translation tools such as Google Translate and MediBabble in hospitals, which increased the satisfaction of both medical providers and patients (to 92%) and improved the quality of healthcare delivery and patient safety. Language barriers are responsible for reducing the satisfaction of medical providers and patients, as well as the quality of healthcare delivery and patient safety. Many healthcare institutions use interpreter services that increase the cost and length of treatment visits.

Conclusions: The results of our review suggest that implementing online translation tools such as Google Translate and MediBabble may improve the quality of healthcare and the level of satisfaction among both medical providers and patients.

Keywords: Communication Barriers; Limited English Proficiency; Patient Satisfaction; Quality of Health Care.

The OMJ is Published Bimonthly and Copyrighted 2020 by the OMSB.

Publication types

• Open access
• Published: 26 July 2021

Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study

• Mamata Pandey 1 ,
• R. Geoffrey Maina 2 ,
• Jonathan Amoyaw 3 ,
• Yiyan Li 2 ,
• Rejina Kamrul 4 ,
• C. Rocha Michaels 4 &
• Razawa Maroof 4  

BMC Health Services Research volume  21 , Article number:  741 ( 2021 ) Cite this article

29k Accesses

63 Citations

14 Altmetric

Metrics details

Immigrants from culturally, ethnically, and linguistically diverse countries face many challenges during the resettlement phase, which influence their access to healthcare services and health outcomes. The “Healthy Immigrant Effect” or the health advantage that immigrants arrive with is observed to deteriorate with increased length of stay in the host country.

An exploratory qualitative design, following a community-based research approach, was employed. The research team consisted of health researchers, clinicians, and community members. The objective was to explore the barriers to healthcare access among immigrants with limited English language proficiency. Three focus groups were carried out with 29 women and nine men attending English language classes at a settlement agency in a mid-sized city. Additionally, 17 individual interviews were carried out with healthcare providers and administrative staff caring for immigrants and refugees.

A thematic analysis was carried out with transcribed focus groups and healthcare provider interview data. Both the healthcare providers and immigrants indicated that limited language proficiency often delayed access to available healthcare services and interfered with the development of a therapeutic relationship between the client and the healthcare provider. Language barriers also impeded effective communication between healthcare providers and clients, leading to suboptimal care and dissatisfaction with the care received. Language barriers interfered with treatment adherence and the use of preventative and screening services, further delaying access to timely care, causing poor chronic disease management, and ultimately resulting in poor health outcomes. Involving untrained interpreters, family members, or others from the ethnic community was problematic due to misinterpretation and confidentiality issues.

Conclusions

The study emphasises the need to provide language assistance during medical consultations to address language barriers among immigrants. The development of guidelines for recruitment, training, and effective engagement of language interpreters during medical consultation is recommended to ensure high quality, equitable and client-centered care.

Peer Review reports

Major immigrant-destination countries like the United States, Germany, Canada, and Australia admit a large share of immigrants from culturally and linguistically diverse countries [ 1 ]. According to the 2016 Canadian Census, foreign-born individuals make up more than one-fifth (21.9%) of the Canadian population, which is close to the highest level (22.3%), recorded in the 1921 Census [ 2 ]. Most immigrants to Canada come from countries like the Philippines, India, China, Nigeria, and Pakistan, where most citizens’ first language is neither English nor French [ 3 , 4 , 5 ]. Individuals without local language proficiency are more likely to have lower income, and face considerable challenges with economic and social integration [ 6 , 7 , 8 ]. These settlement challenges increase the risk of poor health outcomes among newcomers with limited language proficiency [ 9 ]. Newcomers also face inequities in healthcare settings [ 10 ]. Due to immigration requirements, most newcomers are healthier than the general population, an effect referred to as the “healthy immigrant effect.” This effect is observed to decline over time [ 11 , 12 , 13 ]. Limited language proficiency is associated with decline in self-reported health status of new immigrants during the first 4 years of stay in Canada [ 9 ].

The ability to speak the host country’s official language proficiently appears to be an essential determinant of health [ 13 , 14 , 15 , 16 ]. The ability to speak, read, and write in the local language is necessary to communicate with healthcare providers and interact in other social settings [ 17 , 18 , 19 ]. Language is consistently identified as a barrier for immigrants and refugees seeking, accessing, and using mental health services [ 11 , 12 , 15 , 20 ]. Lee and colleagues [ 21 ] argued that Chinese immigrant women are more likely to choose service providers who speak the same language. Marshall, Wong, Haggerty, and Levesque [ 4 ] observed that Chinese- and Punjabi-speaking individuals with limited English language proficiency might delay accessing healthcare to find providers who speak their language. In the absence of culture-specific words and due to stigma, individuals from some ethnics groups may have difficulty describing mental health conditions or describe them as somatic symptoms [ 12 , 22 , 23 , 24 ]. Lack of language support or culturally appropriate services can interfere with timely mental health diagnosis and/or utilization of mental health services [ 12 , 23 , 24 ].

Language-incongruent encounters within the healthcare system increase the risk of inadequate communications, misdiagnosis, medication errors and complications, and even death [ 15 , 19 , 25 ]. Studies indicate that language barriers adversely affect health outcomes, healthcare access, utilization and cost of healthcare services, health-providers’ effectiveness, and patient satisfaction and safety [ 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].

Aery and colleagues [ 34 ] argue that the rights that allow individuals access to language interpreters in the justice system are also applicable in the healthcare context. Without language assistance, individuals with language barriers cannot engage in their treatment, determine risks and benefits of suggested treatment, and/or provide informed consent [ 34 , 35 ]. Human rights legislations in Canada have provided a framework and highlight the necessity to provide language interpreters when needed, but these have not been implemented universally [ 35 ]. Some provinces in Canada have launched language interpretation services. These services include: the Language Services Toronto in Ontario, language services for French-Canadians offered by Winnipeg Health Region in Manitoba and CanTalk telephonic interpreter services approved by the Saskatchewan Health Authority in Saskatchewan [ 35 , 36 , 37 , 38 ]. Professional interpreter services are not covered under most provincial health policies and therefore might not be available in all jurisdictions [ 3 ]. In the absence of universal interpretation services across the country, healthcare providers rely on professional interpreters, interpreters from community-based organizations and/or ad hoc (untrained) interpreters such as family members, friends, and volunteers who lack understanding of medical terminology and disease [ 3 , 36 , 37 , 38 ]. Although the services of professional language interpreters are employed in many Canadian healthcare settings, reliance on ad hoc interpreters, is preponderant [ 35 ]. This is partly due to a lack of trained interpreters in the language required and new immigrants’ lack of knowledge about available language supports [ 10 ]. Providers are also not comfortable with interpreters as it is time consuming, and providers might have different expectations about the roles of interpreters [ 3 ]. The impacts of local language proficiency on immigrants’ health and well-being are relevant and have been studied in other major immigrant-destination countries such as Australia, the United Kingdom, the United States of America [ 15 , 17 , 25 , 32 ].

This topic is particularly relevant in the Canadian context as 72.5% of immigrants are reported to have a mother tongue other than English or French according to the 2016 Census [ 39 ]. Given the unique history, culture, ethnic composition, and organization of healthcare services in Canada, scholars have highlighted the need for Canadian-based studies exploring how language barriers contribute to inefficiencies within the Canadian healthcare system and what strategies can be developed to address the gaps [ 10 , 15 ]. This study explores the impact of language barriers at each point of contact with the healthcare delivery system, from the perspective of immigrants and healthcare providers in a Canadian province that is witnessing a rapid influx of immigrants [ 2 ]. Taking a comprehensive approach, the study examined the overall impacts of language barriers on healthcare access, satisfaction with care received and health outcomes.

The study was set in a mid-size prairie city. An exploratory qualitative research approach guided by the principles of community-based research methods was adopted. Clinicians on the research team experienced many challenges while caring for both immigrants and refugees with language barriers. These clinicians approached community members for their perspective. The study idea was conceived after collective brainstorming with multi-sectoral stakeholders, including: representatives from a non-government settlement agency providing various settlement services to immigrants, family physicians caring for both immigrants and refugees in the city, and health researchers. Each stakeholder represented a specific ethnic-minority group and arrived in Canada as a landed immigrant. Through personal experiences and professional interactions with other immigrants, the stakeholders knew about barriers experienced during healthcare access.

Thereafter, stakeholders developed a research partnership. They collectively decided to document these challenges and leverage the research results to advocate for improved healthcare services. The study aim was to explore the perspectives of immigrants and of healthcare providers. Other groups, such as temporary migrant workers and refugees, have other unique challenges not within the scope of the study. Community partners assisted the research team to finalize the research question and determine methods of participant recruitment. The study was carried out in two parts and approved by the provincial health authority’s research ethics board (REB 14–122 and REB 15–69).

Participants

A purposeful sampling method was used. Community partners assisted with participant recruitment by engaging those seeking services through a settlement agency. All participants recruited were immigrants. The consent form and roles of research participants were shared with all 43 individuals attending English language classes at the settlement agency. Language assistance was provided by interpreters and the English language teachers facilitating the classes. Thirty-seven individuals (28 female and nine male) from 15 different countries signed consent forms. Three participants were travelling, two just began English language classes and one participant was not interested and were excluded. All participants lived in Canada for less than 6 years and are hereafter referred to as “clients.” Please refer to demographic information of clients in Table  1 .

Data collection

The focus group discussion (FGD) questions were developed in consultation with the settlement agency staff and focused on: a) the clients’ perceptions of health and the services needed to stay healthy; b) differences between the healthcare systems in the client’s country of origin and Canada; c) access to healthcare services; d) challenges clients faced when accessing care in Canada; and, e) how clients made decisions about healthcare. Clients received the questions before the FGD to organize their thoughts. Medical students representing specific ethnic groups and speaking an additional language assisted with data collection and interpretation during the FGDs.

Three FGDs were held at the settlement agency and lasted 2 h with breaks for refreshments. Each FGD was attended by 10–15 clients and subgroups of 3–4 clients were coordinated by a facilitator speaking the same language. Clients with language barriers were supported by facilitators speaking their language, other clients with advanced English language proficiency, or language interpreters.

Responses from clients were written down by facilitators and reread to the clients for accuracy. Some clients had written down their thoughts in English using online translators prior to the actual FGD to help them verbalise their thoughts with ease. Clients read out their responses during the FGDs and handed in those written notes after the FGDs. Facilitators also wrote field notes of the salient points emerging from these sessions and their reflections, which informed subsequent FGDs. None of the clients received services from any of the family physicians on the research team during data collection. Complementary child minding, light refreshments and a $20 gift card to a grocery store were provided as incentives to participate.

In part 2, healthcare providers’ perspectives on caring for immigrants and refugees were explored to show a more comprehensive view of the situation. Seventeen healthcare providers and health administrative staff signed the consent form: four family physicians, two family physicians providing obstetrical care, a psychiatrist, a registered nurse, a lab technician, a pharmacist, a nutritionist, a psychiatric social worker, a counsellor, an exercise therapist, an ultrasound technician, an executive director, and a receptionist. They were recruited from a community clinic that predominantly served refugees, immigrants, and other socio-economically disadvantaged populations in the city, other medical clinics in the city, and a hospital.

Healthcare providers serving immigrants and refugees participated in an hour-long, in-depth individual interview focusing on a) health services required to better address the healthcare needs of immigrants and refugees; b) the availability of culturally-responsive healthcare services; and c) the barriers to providing such care. Family physicians on the research team with extensive experience caring for immigrants and refugees assisted with the development of the interview guide and data collection. Interviews were carried out in English and were audio recorded. No compensation was provided.

The FGDs and healthcare provider interviews were transcribed verbatim. Data was analyzed qualitatively using NVivo version 9 following the procedure proposed by Miles, Huberman, and Saldana [ 40 , 41 ]. During preliminary data analysis, two rich transcripts were open coded by a team of researchers. Although the project was carried out to explore barriers to healthcare access for immigrants, language barriers emerged as a distinct theme impacting various aspects of care during data analysis. The results were shared with the settlement agency representatives. A collective decision was made to highlight the impacts of limited English language proficiency on healthcare access, utilization, and outcomes for immigrants in this manuscript. This framework guided the rest of the data analysis. The research team collectively reviewed the completed data analysis report and no new themes emerged at this discussion. The research team collectively agreed that further clarifications were not required from participants. Therefore, follow-up focus groups or interviews were not carried out and no new participants were recruited..

Data was broken into 120 base-level codes. The base-level codes were reviewed a second time, and codes with similar concepts were consolidated into 45 intermediate codes. The intermediate codes were categorized under 11 sub-themes. Title was assigned to each sub-theme to highlight the diverse and pertinent concepts represented by each sub-theme. The sub-themes were then organized under four central themes. Diagrammatic representation shows the relationship between the 11 sub-themes and the four themes and is illustrated in Fig.  1 . Field notes maintained by facilitators were used to cross-reference the themes emerging during data analysis to ensure all pertinent themes were included. The diagram demonstrating the relationship with the subthemes was approved by all team members.

Language Proficiency Leads to Poor Healthcare Access, Suboptimal Care, and Dissatisfaction with Care

Impacts of limited English language proficiency have been summarized under four main themes as follows.

Theme 1: ability to access health information and services

Language proficiency significantly impacted a client’s ability to identify services needed, to secure appointments, and to effectively engage with healthcare providers while seeking care and managing post-appointment care and follow-up. Information about healthcare services is usually provided in English or French. Thus, a client with language barriers lacked adequate information about available services and was unable to access services promptly. Clients with language barriers are less likely to actively seek health and/or mental health services when needed, as is evident from a client’s comment: “ No do not know about mental health services because of the language problem. Can I go to the hospital to access it?” [client]. Another client inquired: “ Do I need appointments for blood tests? ”

The range of healthcare services offered in different countries differs significantly. Lack of knowledge about existing healthcare services in the city created a barrier, which was greatly influenced by clients’ local language proficiency. A healthcare provider in the study commented that,

“We need to make the community or the clients’ population know that this is available for you and this is the process how you get access to this service, the language barrier is a huge barrier for this population and to access like any health care service.”

The way in which healthcare is organized and coordinated varies from country to country, and for newcomers, understanding the services provided within the host country largely depends on their ability to decipher information about them. Those with language limitations might not know how to access various healthcare services. This can lead to misunderstanding between the client and the provider, causing frustrations and unfulfilled expectations for both, as one healthcare provider noted:

“I offer free prescription delivery, but clients didn't come to the door, they didn't understand that the delivery person is delivering it and all they're doing is going to the door, ringing the doorbell expecting them to be let in. On numerous occasions, we were unsuccessful because they [clients] wouldn't open the door, there was no one there or-they did not understand, so, unless someone on the other end speaks English and tells us they're going to be there, we won't deliver now.”

Experience with healthcare delivery in clients’ countries of origin and cultural beliefs about health and what healthcare services should be accessed can interfere with their healthcare access. Language barriers may impede a client’s ability to understand the differences between healthcare organization in Canada and in their country of origin, leading to the underutilization of healthcare services, as one healthcare provider explained:

“If you don't know their language, it becomes difficult to provide care to them. Also, cultural beliefs can interfere with access to care. For example, they [immigrants and refugees with language barrier] do not know how to access an optometrist or dentist. So, I have to give them a lot of information as they have no idea.”

Due to language barriers, clients experienced difficulty following conversations with receptionists, providing proper documentation required for coordinating care, and booking and attending appointments. Clients with language barriers were less likely to seek clarifications when they did not understand instructions or to advocate for their needs. As one client noted, “I don’t speak good English. Therefore, sometimes it is difficult to understand what the receptionist is saying.”

Similarly, a health administrative staff mentioned “I am still waiting for the healthcare number from three clients. They [clients with language barrier] do not understand it is necessary for billing purposes ”.

The degree to which clients with limited language proficiency are able to access the healthcare services they need largely depends on their ability to understand information that is written in English and to understand how the healthcare system is organized.

Theme 2: ability to develop a therapeutic alliance with healthcare providers

English language proficiency significantly affected the therapeutic relationship between patients and healthcare providers. Clients with language barriers were unable to explain their health conditions adequately, as one client noted:

“Without proficiency in English, it is difficult talking to the health care provider. It's a problem to describe what you're feeling. It will be easier as a newcomer if they have a family doctor who speaks the same language. Like for children with pain, it is difficult for them to say what they [children] want or to make them [children] understand .”

Clients reported experiencing difficulty asking questions about their health and understanding treatment instructions. One client mentioned that,

“Sometimes, the doctors describe the illness in a way that I don’t understand what the doctors say. Sometimes this makes it very hard to go to the doctors because of the language problems.”

Healthcare providers were often concerned about not getting adequate information about health concerns from patients with language barriers. They experienced difficulties during physical examinations or when providing treatment instructions, which can have adverse outcomes, as one healthcare provider explained:

“Say I am treating an ear infection. I have told the clients many times that the medication is to be administered by mouth, but they thought it was to be installed in the ears. So, I have a couple of disastrous cases where I have prescribed medication where they don’t realize it is given by mouth. I think also, when they don’t understand, they feel uncomfortable to ask for clarification. They get very embarrassed and they get very frustrated.”

Similarly, clients with English language barriers also mentioned difficulty understanding medication regime as a client mentioned.

“I had problems with the iron levels, the doctors prescribed iron pills. I asked the doctors how many to take, but he did not explain it properly. He first said that I should take one pill a day, then when I ask if that will be enough, he said I can take 2 to 3 pills. How can he advise me like that without explaining it properly?”

Theme 3: challenges with engaging language interpreters

Language interpreters are not available at all clinics and families often bring ad hoc interpreters to the appointments or use volunteers working within the healthcare system. Often, these ad hoc interpreters lack adequate skills and training to carry out medical translation, which creates additional challenges. Healthcare providers may not feel confident that instructions are being translated verbatim. They also noted that often they received a summarized or concise version of what the clients narrated and wondered whether valuable contextual information was lost during translation. This can be frustrating for the healthcare providers and interfere with the development of the therapeutic alliance, as a healthcare provider pointed out:

“Some of the barriers I've experienced, those mainly had to do with communication and interpreters. I guess sometimes I wonder with the translation, what is being said to the patient. because they have quite a long discussion, and then when I ask the interpreter what was said … oh, they have no questions. *laughs* so I'm not sure what the conversation was, so that can be a little bit, um, frustrating.”

Further, some interpreters might provide a cultural and/or religious interpretation of strategies that might not align with Western medical care, as this healthcare provider explained:

“There are times when the clients will bring in their interpreters that I don't feel that my teaching and my advice is being given to them appropriately or word for word. I find that the personal interpreters they bring in will contraindicate and conflict with what I am telling the client because they will say "no that's not how we do things" instead of telling the client what I as a practitioner would like them to do”.

Sometimes, ad hoc interpreters are less helpful in assisting with client-provider communication and they may become an impediment to the therapeutic alliance, as a healthcare provider noted:

“Sometimes working with an interpreter is difficult because you don't always know whether the translator translates exactly what you're trying to come across or explain.”

Some clients were also concerned that their messages were not communicated properly to the healthcare providers during translation as a client mentioned:

“ I cannot speak English so I cannot go by myself to the doctor … … Before I had to wait for my husband he works, and say everything fast as he had to go back to work soon, I could not say everything I wanted, to the doctors, but now my son comes with me so it is better but I have to remind him always to say everything I said, to the doctor as he is still young and may forget .”

A medical interpreter’s presence can create privacy and confidentiality issues, especially for clients with mental health issues. Interpreters assisting clients with mental illness require training to create culturally safe interactions, lest the interaction become more injurious to the clients than the illness itself. The excerpt below from a healthcare provider is an excellent example of culturally unsafe medical translation.

“I had this case where the interpreter was not trained in mental health, and they found the conversation to be funny, so it was an elderly Asian lady who had delusions and hallucinations—well, we had a hard time with that. The interpreter was laughing.”

Some clients were uncomfortable receiving language assistance from family or individuals of the same community. As is mentioned by a women client:

“ I need lady doctor or lady speaking my language. I need medicine to stop baby [contraception] where can I get it. I cannot talk about this with my doctors when others [family members who help with translation] are there with me and I am waiting for 3 months now.”

Moreover, healthcare providers were sometimes concerned about the quality of the translation services provided to their clients. Healthcare providers observed that some interpreters struggled to explain instructions adequately during sample collection and diagnostics tests, leading to delays in the treatment process and linkage to treatment. One healthcare provider conveyed the issues with inadequate medical translation:

“I requested that the client present with a stool sample in the container provided. A couple of times, some clients showed up with urine in there rather than stool. This is after numerous explanations with an interpreter present.”

Another healthcare provider mentioned that:

“Giving simple instructions such as the need for a full bladder before ultrasound, many don’t understand what bladder is. Last week I tried to conduct spirometry on a patient even with the presence of an interpreter and I was not successful. He just didn't understand. I guess he [interpreter] did not translate accurately.”

Effective communication between healthcare providers and clients is vital for providing safe and quality healthcare.

Theme 4: impacts of language barriers on health outcome and strategies addressing gaps

Clients with language barriers often manage care on their own and due to lack of effective communication they are often dissatisfied with care received. Clients felt as though it was not worth seeking care when there was no means of addressing their language limitations, as one client noted:

“This country has so much resources and sometimes I feel the resources are not put to good use . What is the point of seeing a doctor if I do not feel satisfied? First, you must make appointments, manage everything at home to go for that appointment, and then still wait when you reach there, and then the doctors hardly spend time with you.”

In many countries healthcare is accessed on a need to basis and individuals might not have understanding about preventative health. Emphasis is given on preventative medicine in Canada, but providing health education can be challenging due to language barriers as a healthcare provider pointed out:

“If they don’t understand the preventative or the treatment plan but instead of perhaps doing some preventative stuff, they want to jump right to the surgery or jump right to the medication. Like PAP smears and mammograms, there is a lack of education in those countries where they come from. There are no concepts of preventative health care there. We tried to offer an information session with interpreters it really slowed down the meeting; everyone had to wait for the interpreter to interpret our directions and if we didn’t immediately have them interpret the participants were having a hard time following the conversation”

Healthcare providers were apprehensive about the dangers that clients with language barriers might face away from healthcare setting, as was explained by this healthcare provider:

“First of all, they [clients] might not understand what I'm telling them when I'm asking them to administer insulin themselves and increasing their doses based on their numbers. A lot of times they’re very confused on that fact and the translation, something is getting lost in the translation. Any misunderstanding can put them in a very dangerous situation if they give themselves too much insulin.”

Language ability can interfere with chronic disease management, which requires continual monitoring through regular clinic appointments. Even with medical translation, some clients may not comprehend the steps in the treatment plan that they are required to follow to manage chronic conditions effectively. Without additional supports available after medical appointments, these patients struggle to set up follow-up appointments, refill prescriptions, and adhere to medical instructions. In the absence of supports, treatment adherence might be poor. A healthcare provider describes what happens when clients don’t receive post-appointment follow-up or support:

“A lot of them [clients] have chronic conditions such as hypertension and don't come for a routine check-up. You'll see them and start them on medication and try to emphasize that this is long term treatment, and they will need to come back in a month for a check-up. You'll see that they've shown up a year later, and yet they were prescribed medications to last them for one month only and didn't renew them even though they had renewals. They will show up a year later with a headache or something, and their blood pressure is way out of control. I see that a lot.”

Clients mentioned adopting few strategies to address language barriers. Women clients often preferred same gender interpreters for women health issues and they depended on family and friend circles for assistance as a client mentioned: “ I have a very good friend who took holiday from work to come with me, I had to talk to the doctor about women problem .” Clients also consulted friends or family to find relevant healthcare services near them. A client mentioned: “I will ask my sister for healthcare for my family she and her family help us when we need information. I can also find out using the internet.” Clients might also seek information about healthcare services and ways to access it from community organizations providing settlement services as a client mentioned: “ I ask my English teacher when I need information about healthcare services they can help me. ”

Some clients pointed out that finding providers from their ethnic background would be helpful. Many clients take it upon themselves to seek care from these providers and may delay healthcare access, as this participant mentioned: “I am waiting to find a doctor who speak my language and can understand my culture.” Matching clients with providers from the same linguistic and ethnic background is useful but challenging. It may be more feasible in larger cities with larger and established ethnic groups. A client who received care from a provider from the same ethnic background mentioned a positive experience, as is evident from this comment:

“My doctor is from my country and he was able to explain to me why I need the surgery (hysterectomy). I was scared and I did not want to do it, but my husband and my doctor helped me understand that it was needed and if I did not get it done I will get very sick, I did it and I am alright now.”

Alternatively, healthcare providers who are culturally attuned to the challenges that clients with language barriers face are often empathetic and accommodative and ensure that clients receive the required care. One healthcare provider noted:

“They experience barriers accessing health care due to language limitations. Some clients may have challenges with conceptualizing what constitutes good health. This is partly informed by the fact that most of them may have experienced marginalization for so long. Therefore, [clients] might not have the right access to information or ask the right question. I try to talk to them at their level of understanding.”

Specialized clinics providing services to immigrants and refugees might have trained interpreters; however, their time might be limited, and they might not be available for healthcare services outside the clinics. One healthcare provider mentioned:

“We are lucky to have interpreters in our clinic but their time is limited and most of their time is allocated for in-person appointments in the clinics and they might not be available to provide support for other program such as health promotion.”

To achieve a positive treatment outcomes among immigrants with language barriers, effective coordination of care, good patient-provider communication and assistance with follow-up into the community post appointment are required. Lack of these ancillary services discourages individuals from accessing healthcare services. This is evident from a client’s comments:

“ I cannot speak English well and so cannot explain what I need I got so frustrated with the doctors did not go to see one in one whole year but that came to harm me. I now have pain in my ankle which is growing but what is the use of telling the doctors I cannot explain properly and they will not understand and it will not help .”

Individuals might delay access to healthcare which increases patients’ vulnerability to adverse health outcomes.

This study includes the perspectives of immigrants in a Canadian city and healthcare providers serving them. Consistent with the literature, both patients and providers unanimously agreed that limited English language proficiency significantly impacts access to care, quality of care received, and health outcomes for immigrants throughout the continuum of care [3, 10, 15–17, 26–29, 31, 33]. This study examined the impacts of language barriers at all points of contact with the healthcare delivery system. The study highlights that the impacts of language barriers are evident long before an individual meets with a healthcare provider and persist long after an individual has received a treatment or intervention. The cumulative impact of this is delayed access to timely healthcare, suboptimal care, increased risk of adverse events, dissatisfaction with care received and poor health outcomes. The study emphasizes that healthcare delivery in Canada cannot be improved by providing language interpreters during medical consultation alone. A more comprehensive approach is required that includes, developing best practice guidelines for providers, training for interpreters and policy change to address the impacts of language barriers on healthcare delivery, utilization and health outcomes in Canada. This study highlights four ways in which limited English language proficiency can interfere with immigrants’ healthcare access and health outcomes.

As observed by Floyd and Sakellariou [ 29 ], clients in our study were unaware of the available healthcare services, lacked knowledge about ways to navigate the healthcare system, and were unable to advocate for needed services [ 25 ]. Language barriers impacted clients’ engagement with prevention, health promotion, and allied health services, which can create the misperception that they are disengaged in care. Other studies have also identified that language barriers influence access to and use of preventative medicine and screening [ 30 , 42 , 43 , 44 ]. Language barriers interfere with the ability to find information about healthcare services and eligibility. This leads to fragmented, suboptimal care and/or delayed linkage with appropriate care [ 4 , 30 ].

Clients and providers consistently mentioned that language barriers interfered with the development of therapeutic relationships. As observed in other studies, language barriers impeded effective health information sharing and communication between patients and providers, thereby undermining trust [ 16 , 26 , 27 , 28 , 29 , 30 ]. Similar to what De Moissac and Bowen [ 38 ] observed, the clients in this study also mentioned difficulty describing pain and other symptoms to their healthcare providers, which can interfere with accurate diagnoses [ 25 , 32 , 45 ]. Clients with limited language abilities are at risk of delaying treatment [ 4 , 38 ], misdiagnosis, or mismanagement of their conditions [ 38 , 46 ]. Like those reported in other studies, our results also demonstrated specific instances where language barriers increased the chances of medical errors and harms due to patient’s inability to understand and/or follow treatment plans [ 15 , 17 , 25 , 38 ].

Consistent with the findings of systematic reviews [ 16 , 47 ], the providers in this study indicated that interpreters were helpful. As observed in other studies [ 16 , 29 , 30 ], clients in this study also emphasized the need for bilingual healthcare providers. Community health navigators can help improve access to primary and preventative healthcare services while acting as cultural brokers and language interpreters [ 48 ]. Molina and Kasper called for language-concordant care, as it has been shown to provide safe and high-quality care [ 49 ].

However, this study adds to the discussion in the literature about the challenges that arise when ad hoc interpreters are involved [ 50 ]. Consistent with the literature, the healthcare providers in this study indicated that interpreters’ roles are often unstructured. Instead of verbatim translating, an interpreter might summarize information or provide their own interpretation of what the patient and/or the provider said, leading to suboptimal conversation and care [ 3 , 42 ]. Interpreters are also unsure about their role in medical translation [ 18 ]. Although healthcare providers wanted verbatim translation in our study, other studies observed that healthcare providers might expect interpreters to also act as cultural brokers or care coordinators [ 3 , 18 , 42 ]. Our results provided evidence of situations when some medical interpreters could not provide culturally safe translation support, especially when sensitive and taboo topics were involved [ 3 ]. Providers might not feel comfortable or prepared to care for immigrants with language barriers [ 25 ]. Language barriers may slow down conversations and additional follow-ups are required thereby increasing stress and workload for providers [ 27 , 42 , 47 , 51 ].

In this study, clients and providers both indicated that multiple sessions might be required to communicate instructions for treatment and sample collection [ 42 ]. As observed by Ali and Watson [ 17 ] in the United Kingdom, the healthcare providers in this study also reported that interpreters might not be able to translate treatment plans, instructions for sample collection, or instructions for screenings because of their lack of medical knowledge. As discussed in the literature, the healthcare providers in this study also highlighted issues with privacy and confidentiality when ad hoc interpreters, family members, or individuals from the same ethnic groups are involved [ 3 , 43 , 50 , 52 ]. Studies indicate that clients with limited English language proficiency prefer professional gender-concordant interpreters over family members [ 53 ]. Although studies show that without medical interpreters the quality of care is compromised for clients with language barriers, interpretation errors often occur when ad hoc interpreters are used [ 10 , 16 , 25 , 26 , 50 , 52 , 54 ]. Professional interpreters raise the quality of clinical care compared to ad hoc interpreters [ 50 , 54 ].

Finally, the present study highlighted how English language proficiency creates an additional layer of barriers to healthcare access, utilization, and patient satisfaction [ 3 ]. Inability to communicate effectively with healthcare providers creates dissatisfaction for patients because their needs were not communicated and they are not getting the services needed [ 16 , 27 ]. Moreover, language barriers limit a healthcare provider’s ability to provide care in a timely, safe manner; subsequently, the client’s needs are unmet [ 4 , 16 , 17 , 27 , 32 ].

Language barriers also create dissatisfaction for healthcare providers as they are unable to engage patients in health promotion and preventative programs [ 42 , 44 ], offer additional supports like home delivery for medications, or support them with treatment adherence. Language barriers might cause embarrassment, disempower patients, and undermine patients’ confidence [ 25 , 28 , 30 ]. Floyd & Sakellariou [ 29 ] observed that refugee women with language barriers are likely to experience racism, and might not be engaged in healthcare decision making. Additionally, cultural belief and experience with the healthcare delivery system in the country of origin influence the type of healthcare services that will be accessed and expectation from healthcare providers [ 3 , 28 , 30 ]. Due to a lack of culturally appropriate care, access to healthcare services can be delayed or underutilized [ 12 , 24 , 30 , 31 ].

Floyd and Sakellariou [ 29 ] observed that the Canadian healthcare system is organized on the assumption that service seekers can read and understand English, which marginalizes immigrants, refugees, and others with lower literacy and limited English language proficiency.

Parsons, Baker, Smith-Gorvie, and Hudak [ 55 ] mention that it is unclear who is responsible for ensuring that communication between providers and patient is adequate. Guidelines are required for healthcare providers outlining when interpreters should be involved. Papic et al. [ 47 ] highlighted the need for clear directives for determining who is responsible for arranging interpreters and finding ways to enhance the involvement of professional interpreters and multicultural clinics where available.

As a country that promotes and celebrates multiculturalism, the Canadian Charter of Rights and Freedoms (1982) guarantees equal rights, such that Canadians are to be treated with the same respect, dignity, and consideration regardless of race, nationality, ethnicity, color, religion, sex, or age [ 56 ]. Healthcare access needs to be regarded as a basic human right under the Charter and not be contingent on language proficiency. Although most immigrants arrive with better health status than the local population, largely attributed to initial health selectivity and the Canadian immigration policy, their health status tends to decline over time to levels worse than native-born citizens [ 3 , 57 , 58 , 59 , 60 ]. This deterioration has been partly attributed to discrimination and unfair treatment that immigrants experience in the healthcare system [ 60 ].

Aery [ 61 ] proposed that a health equity perspective is required to address the socio-cultural barriers faced by vulnerable populations, including immigrants and refugees. Ali and Waston [ 17 ] proposed that addressing language barriers is an essential step towards providing culturally responsive and client-centered care. The importance of enabling patients to actively participate in their healthcare has received extensive policy attention [ 62 ]. Giving patients an active role in their healthcare empowers them and improves services and health outcomes [ 63 ]. Involving patients in shared decision making is emphasised in Saskatchewan, Canada [ 64 ]. Against this backdrop, patients, providers, and interpreters in Canada need to be engaged to understand the multi-layer barriers at the individual, community, and health-system levels and address those needs [ 42 ].

Limitation of the study

A small number of clients from each ethnic group was recruited; therefore, results might not reflect the experience of the respective ethnic groups as a whole. With a larger number of female clients recruited in the study, the views are more reflective of female than male patients with language barriers. A small number of healthcare providers were recruited from each discipline. Further research is required to capture discipline-specific challenges encountered by providers caring for patients with language barriers. The study did not include migrant workers and refugees and additional research is required to highlight specific challenges experienced by specific groups.

Implications for practice

The results of the study are relevant for any country accepting immigrants from linguistically diverse countries. Through professional courses, continued education, and development of best practice guidelines healthcare providers in Canada should be equipped with adequate knowledge and skills to care for patients with language barriers [ 49 ].

Interpreters in Canada should have clear instructions about whether only verbatim translation is required or they need to serve as cultural brokers and/or support clients with coordination of care. A national strategy should be developed in Canada to train, support, and supervise interpreters adequately to ensure that they deliver safe, and impactful services [ 35 ].

Availability of data and materials

All data generated or analysed during this study are available from the corresponding author on reasonable request.

International Organization for Migration (IOM). World Migration Report 2020, UN, New York; 2019. p. 492. [cited 2021 Feb 26] Available from https://doi.org/10.18356/b1710e30-en .

Statistic Canada. Immigration and ethnocultural diversity: key results from the 2016 census [internet]. Ottawa: Statistics Canada; 2017. p. 8. [cited 2021 Feb 26]. Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/171025/dq171025b-eng.pdf?st=WbM3u6Dy .

Ahmed S, Shommu NS, Rumana N, Barron GR, Wicklum S, Turin TC. Barriers to access of primary healthcare by immigrant populations in Canada: a literature review. J Immigr Minor Health. 2016;18(6):1522–40. https://doi.org/10.1007/s10903-015-0276-z .

Article   PubMed   Google Scholar  

Marshall EG, Wong ST, Haggerty JL, Levesque JF. Perceptions of unmet healthcare needs: what do Punjabi and Chinese-speaking immigrants think? A qualitative study. BMC Health Serv Res. 2010;10(1):1–8.

Article   Google Scholar  

Refugee I, Canada C. 2020 Annual report to parliament on immigration [internet]: Immigration, Refugee and citizenship Canada; 2020. [cited 2021 march 14]. 41p. Cat. No. Ci1E-PDF. Available from: https://www.canada.ca/content/dam/ircc/migration/ircc/english/pdf/pub/annual-report-2020-en.pdf

Boyd M, Cao X. Immigrant language proficiency, earnings, and language policies. Canadian Studies in Population [ARCHIVES]. 2009;36(1–2):63–86. https://doi.org/10.25336/P6NP62 .

Dustmann C, Fabbri F. Language proficiency and labour market performance of immigrants in the UK. Econ J. 2003;113(489):695–717.

Sakamoto I, Ku J, Wei Y. The deep plunge: Luocha and the experiences of earlier skilled immigrants from mainland China in Toronto. Qual Soc Work. 2009;8(4):427–47. https://doi.org/10.1177/1473325009346518 .

Ng E, Pottie K, Spitzer D. Official language proficiency and self-reported health among immigrants to Canada. Health Rep. 2011;22(4):15-23.

Laher N, Sultana A, Aery A, Kumar N. Access to language interpretation services and its impact on clinical and patients outcomes: a scoping review. Toronto: Wellesley Institute: Advancing Urban Health; 2018. p. 1–78.

Google Scholar  

Delara M. Social determinants of immigrant women’s mental health. Adv Public Health. 2016;2016:1–11. https://doi.org/10.1155/2016/9730162 .

Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ. 2011;183(12):E959–67. https://doi.org/10.1503/cmaj.090292 .

Article   PubMed   PubMed Central   Google Scholar  

Thomson EF, Andrea M, Noack AM, George U. Health Decline Among Recent Immigrants to Canada: Findings From a Nationally-representative Longitudinal Survey. Can J Public Health. 2011;102(4):273–80.

Luiking ML, Heckemann B, Ali P, Dekker-van Doorn C, Ghosh S, Kydd A, et al. Migrants’ healthcare experience: a meta-ethnography review of the literature. J Nurs Scholarsh. 2019;51(1):58–67. https://doi.org/10.1111/jnu.12442 .

Bowen S. The impact of language barriers on patient safety and quality of care. Société Santé Français. 2015. p. 53.

Joshi C, Russell G, Cheng IH, Kay M, Pottie K, Alston M, et al. A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination. Int J Equity Health. 2013;12(1):1–4. https://doi.org/10.1186/1475-9276-12-88 .

Ali PA, Watson R. Language barriers and their impact on provision of care to patients with limited English proficiency: Nurses' perspectives. J Clin Nurs. 2018;27(5–6):e1152–60. https://doi.org/10.1111/jocn.14204 .

Messias DK, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters. Adv Nurs Sci. 2009;32(2):128–43. https://doi.org/10.1097/ANS.0b013e3181a3af97 .

Poureslami I, Rootman I, Doyle-Waters MM, Nimmon L, FitzGerald JM. Health literacy, language, and ethnicity-related factors in newcomer asthma patients to Canada: a qualitative study. J Immigr Minor Health. 2011;13(2):315–22. https://doi.org/10.1007/s10903-010-9405-x .

Sumin N, Andrew R, Laurence K. Towards a culturally responsive model of mental health literacy: facilitating help-seeking among east Asian immigrants to North America. Am J Community Psychol. 2016;58(1/2):211–22.

Lee TY, Landy CK, Wahoush O, Khanlou N, Liu YC, Li CC. A descriptive phenomenology study of newcomers’ experience of maternity care services: Chinese women’s perspectives. BMC Health Serv Res. 2014;14(1):1–9.

Anand AS, Cochrane R. The mental health status of south Asian women in Britain: a review of the UK literature. Psychol Dev Soc. 2005;17(2):195–214. https://doi.org/10.1177/097133360501700207 .

Chen AW. Immigrant access to mental health services: conceptual and research issues. Canadian Issues. 2010. p. 51-54. https://multiculturalmentalhealth.ca/wp-content/uploads/2019/07/Immigrant_mental_health_10aug10.pdf .

Fang L. Mental health service utilization by Chinese immigrants: barriers and opportunities. Canadian Issues. 2010. p. 70-74. https://multiculturalmentalhealth.ca/wp-content/uploads/2019/07/Immigrant_mental_health_10aug10.pdf .

Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659–66. https://doi.org/10.1097/MOP.0000000000000404 .

Ahmed S, Lee S, Shommu N, Rumana N, Turin T. Experiences of communication barriers between physicians and immigrant patients: a systematic review and thematic synthesis. Patient Experience J. 2017;4(1):122–4. https://doi.org/10.35680/2372-0247.1181 .

Al Shamsi H, Almutairi AG, Al Mashrafi S, Al KT. Implications of language barriers for healthcare: a systematic review. Oman Med J. 2020;35(2):e122. https://doi.org/10.5001/omj.2020.40 .

Dastjerdi M, Olson K, Ogilvie L. A study of Iranian immigrants’ experiences of accessing Canadian health care services: a grounded theory. Int J Equity Health. 2012;11:55. https://doi.org/10.1186/1475-9276-11-55 .

Floyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: layers of disadvantage. Int J Equity Health. 2017;16(1):1–0.

George P, Terrion JL, Ahmed R. Reproductive health behaviour of Muslim immigrant women in Canada. Int J Migration Health Soc Care. 2014;10(2):88-101.  https://doi.org/10.1108/IJMHSC-09-2013-0032 .

Higginbottom G, Safipour J. Access to primary health care by new and established immigrants in Canada. J Fam Med Commun Health. 2015;2(5):1–7.

van Rosse F, de Bruijne M, Suurmond J, Essink-Bot ML, Wagner C. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016;54:45–53. https://doi.org/10.1016/j.ijnurstu.2015.03.012 .

Gulati S, Watt L, Shaw N, Sung L, Poureslami IM, Klaassen R, et al. Communication and language challenges experienced by Chinese and south Asian immigrant parents of children with cancer in Canada: implications for health services delivery. Pediatr Blood Cancer. 2012;58(4):572–8. https://doi.org/10.1002/pbc.23054 .

Aery A, Kumar N, Laher N, Sultana A. (2017). Interpreting consent – a rights based approach to language accessibility in Ontario’s health care system: Wellesley institute; 2017. p. 1–14. Retrieved from: http://www.wellesleyinstitute.com/publications/interpreting-consent-a-rights-based-approach-to-language-accessibility-in-ontarios-health-care-system/

Bowen S. Language barriers in access to health care. Ottawa: Health Canada; 2001.

Tam V, Buchana F, Lurette C. How do we ensure that patients receive care in their own languages? [internet]. Healthydebate. 2018; [updated 2018 Dec13; cited 2021 April26]. Available from https://healthydebate.ca/2018/12/topic/language-interpretation-in-health-care/ .

Kumar N, Laher N, Sultana A, Aery A. The right to language accessibility in Ontario’s Healthcare system. [internet]: Wellesley Institute; 2017. [cited 2021 April24]. Available from https://www.wellesleyinstitute.com/health/the-right-to-language-accessibility-in-ontarios-health-care-system/

De Moissac D, Bowen S. Impact of language barriers on quality of care and patient safety for official language minority Francophones in Canada. J Patient Experience. 2019;6(1):24–32. https://doi.org/10.1177/2374373518769008 .

Census. Linguistic integration of immigrants and official language populations in Canada. Statistic Canada. 2017. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016017/98-200-x2016017-eng.cfm

Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook: Sage publications; 2018.

QSR International Pty Ltd. Powerful research, simplified [Internet]. Doncaster: QSR International Pty Ltd; [cited 2021 Feb 26]. Available from: https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/about/nvivo .

Bruce KH, Schwei RJ, Park LS, Jacobs EA. Barriers and facilitators to preventive cancer screening in limited English proficient (LEP) patients: physicians’ perspectives. Commun Med. 2014;11(3):235. https://doi.org/10.1558/cam.v11i3.24051 .

Marques P, Nunes M, da Luz AM, Heleno B, Dias S. Factors associated with cervical cancer screening participation among migrant women in Europe: a scoping review. Int J Equity Health. 2020;19(1):1–5.

Ferdous M, Lee S, Goopy S, Yang H, Rumana N, Abedin T, et al. Barriers to cervical cancer screening faced by immigrant women in Canada: a systematic scoping review. BMC Womens Health. 2018;18(1):1–3. https://doi.org/10.1186/2Fs12905-018-0654-5 .

Bischoff A, Bovier PA, Isah R, Françoise G, Ariel E, Louis L. Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral. Soc Sci Med. 2003;57(3):503–12. https://doi.org/10.1016/s0277-9536(02)00376-3 .

Reitmanova S, Gustafson DL. “They can’t understand it”: maternity health and care needs of immigrant Muslim women in St. John’s, Newfoundland. Matern Child Health J. 2008;12(1):101–11. https://doi.org/10.1007/s10995-007-0213-4 .

Papic O, Malak Z, Rosenberg E. Survey of family physicians’ perspectives on management of immigrant patients: attitudes, barriers, strategies, and training needs. Patient Educ Couns. 2012;86(2):205–9. https://doi.org/10.1016/j.pec.2011.05.015 .

Shommu NS, Ahmed S, Rumana N, Barron GR, McBrien KA, Turin TC. What is the scope of improving immigrant and ethnic minority healthcare using community navigators: a systematic scoping review. Int J Equity Health. 2016;15(1):1–2. https://doi.org/10.1186/s12939-016-0298-8 .

Molina RL, Kasper J. The power of language-concordant care: a call to action for medical schools. BMC Med Educ. 2019;19(1):1–5.

Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255–99. https://doi.org/10.1177/1077558705275416 .

Gerchow L, Burka LR, Miner S, Squires A. Language barriers between nurses and patients: a scoping review. Patient Educ Couns. 2021;104(3):534-53. https://doi.org/10.1016/j.pec.2020.09.017 .

Squires A. Evidence-based approaches to breaking down language barriers. Peer Rev J Clin Excellence. 2017;47(9):34–40.

Ngo-Metzger Q, Massagli MP, Clarridge BR, Manocchia M, Davis RB, Iezzoni LI, et al. Linguistic and cultural barriers to care. J Gen Intern Med. 2003 Jan;18(1):44–52. https://doi.org/10.1046/j.1525-1497.2003.20205.x .

Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–54. https://doi.org/10.1111/j.1475.6773.2006.00629.x .

Parsons JA, Baker NA, Smith-Gorvie T, Hudak PL. To ‘get by’or ‘get help’? A qualitative study of physicians’ challenges and dilemmas when patients have limited English proficiency. BMJ Open. 2014;4:e004613.  https://doi.org/10.1136/bmjopen-2013-004613 .

Department of Justice Canada. The rights and freedoms the Charter protects [Internet]. Ottawa: Department of Justice Canada; 2018. [cited 2021 Feb 26]. Available from: https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/rfcp-cdlp.html

Jass G, Massey DS. Immigrant health: selectivity and acculturation. IFS Working Papers; 2004.

Riosmena F, Kuhn R, Jochem WC. Explaining the immigrant health advantage: self-selection and protection in health-related factors among five major national-origin immigrant groups in the United States. Demography. 2017;54(1):175–200. https://doi.org/10.1007/s13524-016-0542-2 .

Vang ZM, Sigouin J, Flenon A, Gagnon A. Are immigrants healthier than native-born Canadians? A systematic review of the healthy immigrant effect in Canada. Ethn Health. 2017;22(3):209–41. https://doi.org/10.1080/13557858.2016.1246518 .

De Maio FG, Kemp E. The deterioration of health status among immigrants to Canada. Global Public Health. 2010;5(5):462–78. https://doi.org/10.1080/17441690902942480 .

Aery A. Innovations to champion access to primary care for immigrants and refugees: Wellesley Institute: Advancing Urban Health; 2017. p. 1–14.

Staniszewska S. Patient and public involvement in health services and health research: a brief overview of evidence, policy and activity. J Res Nurs. 2009;14(4):295–8. https://doi.org/10.1177/1744987109106811 .

Vahdat S, Hamzehgardeshi L, Hessam S, Hamzehgardeshi Z. Patient involvement in health care decision making: a review. Iran Red Crescent Med J. 2014;16(1):e12454. https://doi.org/10.5812/ircmj.12454 .

Saskatchewan Health Authority. Primary healthcare for patients. [internet]. Saskatchewan Health Authority [cited 2021 April26]. Available from https://www.saskatchewan.ca/residents/health/accessing-health-care-services/primary-health-care/patients .

Download references

Acknowledgements

We greatly appreciate the support received from the Executive Director of Regina Immigrant Women Center Mrs. Neelu Sachdev and her staff members during the project. We would especially like to thank the teachers facilitating the English language classes, for helping with participant recruitment, data collection, translation and data interpretation. We acknowledge the contributions of Cheghaf Madrati, Sarah Green Wood, Tooba Zahid, Fatima Ahmed and Tannys Bozdech undergraduate medical students who provided language support and assisted with writing the response during the focus group discussion. We also want to thank psychiatry resident Samra Sahlu for assistance with the healthcare provider interviews. Saskatchewan Health Authority and Department of Academic Family Medicine (Regina Campus) University of Saskatchewan provided in-kind support for the project.

This project did not receive any financial support.

Author information

Authors and affiliations.

Research Department, Wascana Rehabilitation Centre, Saskatchewan Health Authority, 2180-23rd Ave, Regina, SK, S4S 0A5, Canada

Mamata Pandey

College of Nursing, University of Saskatchewan, Prince Albert, SK, Canada

R. Geoffrey Maina & Yiyan Li

Department of Sociology and Social Anthropology, Dalhousie University, Halifax, NS, Canada

Jonathan Amoyaw

Department of Academic Family Medicine, University of Saskatchewan, Regina, SK, Canada

Rejina Kamrul, C. Rocha Michaels & Razawa Maroof

You can also search for this author in PubMed   Google Scholar

Contributions

Mamata Pandey: She developed the research plan, carried out stake holder consultation, prepared ethics application, collected data, analyzed data, prepared the first draft of the manuscript. Geoffrey Maina: Assisted with finalizing methodology, data analysis, writing methodology, data analysis, results and implication section of the manuscript, extensively review and revised the manuscript. Jonathan Amoyaw: Assisted with literature review, prepared the discussion, limitation and conclusion, reviewed and edited the manuscript. Yiyan Li: Assisted with introduction, literature review, figures and tables and final editing of manuscripts. Rejina Kamrul: Helped with ethics application, carried out consultation with community partners, development of focus group and health care provider interview guides, data collection and analysis and reviewed the final draft of the manuscripts. Clara Rocha Michaels: Assisted with consultation with stakeholders, reviewed ethics application, development of healthcare provider interview guides, data collection, data analysis and reviewed the final draft of the manuscripts. Razawa Maroof: Assisted with ethics application for part 2 of the study, assisted in the development of the interview questions for healthcare providers, carried out interviews with healthcare providers, reviewed the data analysis and final draft of the manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Mamata Pandey .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Research Ethics Board at Saskatchewan Health Authority, Regina, Saskatchewan, Canada (REB 14–122 and REB 15–69). All protocols were carried out in accordance with relevant guidelines and regulations. All participants provided informed consent before participating in the research activity.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Pandey, M., Maina, R.G., Amoyaw, J. et al. Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study. BMC Health Serv Res 21 , 741 (2021). https://doi.org/10.1186/s12913-021-06750-4

Download citation

Received : 03 March 2021

Accepted : 12 July 2021

Published : 26 July 2021

DOI : https://doi.org/10.1186/s12913-021-06750-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Language barriers
• Healthcare access
• Healthcare utilisation
• Health outcomes

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

• Open access
• Published: 13 December 2023

Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review

• Jeongok Park   ORCID: orcid.org/0000-0003-4978-817X 1 ,
• Sang Bin You   ORCID: orcid.org/0000-0002-1424-4140 2 ,
• Gi Wook Ryu   ORCID: orcid.org/0000-0002-4533-7788 3 &
• Youngkyung Kim   ORCID: orcid.org/0000-0002-3696-5416 4  

Systematic Reviews volume  12 , Article number:  230 ( 2023 ) Cite this article

823 Accesses

1 Altmetric

Metrics details

Intravenous (IV) medication is commonly administered and closely associated with patient safety. Although nurses dedicate considerable time and effort to rate the control of IV medications, many medication errors have been linked to the wrong rate of IV medication. Further, there is a lack of comprehensive studies examining the literature on rate control of IV medications. This study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing and synthesizing the existing literature.

This scoping review was conducted using the framework proposed by Arksey and O’Malley and PRISMA-ScR. Overall, four databases—PubMed, Web of Science, EMBASE, and CINAHL—were employed to search for studies published in English before January 2023. We also manually searched reference lists, related journals, and Google Scholar.

A total of 1211 studies were retrieved from the database searches and 23 studies were identified from manual searches, after which 22 studies were selected for the analysis. Among the nine project or experiment studies, two interventions were effective in decreasing errors related to rate control of IV medications. One of them was prospective, continuous incident reporting followed by prevention strategies, and the other encompassed six interventions to mitigate interruptions in medication verification and administration. Facilitators and barriers related to rate control of IV medications were classified as human, design, and system-related contributing factors. The sub-categories of human factors were classified as knowledge deficit, performance deficit, and incorrect dosage or infusion rate. The sub-category of design factor was device. The system-related contributing factors were classified as frequent interruptions and distractions, training, assignment or placement of healthcare providers (HCPs) or inexperienced personnel, policies and procedures, and communication systems between HCPs.

Conclusions

Further research is needed to develop effective interventions to improve IV rate control. Considering the rapid growth of technology in medical settings, interventions and policy changes regarding education and the work environment are necessary. Additionally, each key group such as HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices should perform its role and cooperate for appropriate IV rate control within a structured system.

Peer Review reports

Medication errors are closely associated with patient safety and the quality of care [ 1 , 2 ]. In particular, medication errors, which denote a clinical issue of global importance for patient safety, negatively affect patient morbidity and mortality and lead to delays in discharge [ 3 , 4 ]. The National Health Service in the UK estimates that 237 million medication errors occur each year, of which 66 million cause clinically significant harm [ 5 ]. The US Food and Drug Administration reported that they received more than 100,000 reports each year associated with suspected medication errors [ 6 ]. Additionally, it was estimated that 40,000–98,000 deaths per year in the USA could be attributed to errors by healthcare providers (HCPs) [ 7 ]. Previous studies have revealed that medication errors account for 6–12% of hospital admissions [ 8 ].

Intravenous (IV) medication is a common treatment in hospitalized patient care [ 9 ]. It is used in wards, intensive care units (ICUs), emergency rooms, and outpatient clinics in hospitals [ 9 , 10 ]. As direct HCPs, nurses are integral in patient safety during the IV medication process which could result in unintended errors or violations of recommendations [ 3 ]. As many drugs injected via the IV route include high-risk drugs, such as chemotherapy agents, insulin, and opioids [ 10 ], inappropriate dose administration could lead to adverse events (AEs), such as death and life-threatening events [ 11 , 12 ].

IV medication process is a complex and multistage process. There are 12 stages in the IV medication process, which can be classified as follows: (1) obtain the drug for administration, (2) obtain the diluent, (3) reconstitute the drug in the diluent, (4) take the drug at the patient’s bedside, (5) check for the patient’s allergies, (6) check the route of drug administration, (7) check the drug dose, (8) check the patency of the cannula, (9) expel the air from the syringe, (10) administer the drug, (11) flush the cannula, and (12) sign the prescription chart [ 13 ]. IV medication errors can occur at any of these stages. It is imperative to administer the drug at the correct time and rate during the IV medication process [ 13 ]. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defined an error in IV medication rates as “too fast or too slow rate than that intended” [ 14 ]. Maintaining the correct rate of IV medication is essential for enhancing the effectiveness of IV therapy and reducing AEs [ 9 ].

Infusion pumps are devices designed to improve the accuracy of IV infusions, with drug flow, volume, and timing programmed by HCPs [ 15 ]. A smart pump is an infusion pump with a software package containing a drug library. During programming, the smart pump software warns users about entering drug parameters that deviate from the recommended parameters, such as the type, dose, and dosage unit of the drug [ 15 ]. In the absence of a device for administering IV medication, such as an infusion pump or smart pump, the IV rate is usually controlled by counting the number of fluid drops falling into the drip chamber [ 9 ].

According to the previous study, applying an incorrect rate was the most prevalent IV medication error, accounting for 536 of 925 (57.9%) total IV medication errors [ 16 ]. Although rate control of IV medications is critical to patient safety and quality care, few studies review and map the relevant literature on rate control of IV medications. Therefore, this study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing the existing literature.

The specific research questions of this study are as follows:

What are the general characteristics of the studies related to rate control of IV medications?

What are the attributes of errors associated with rate control of IV medications?

What are the facilitators and barriers to rate control of IV medications?

This scoping review followed the framework suggested by Arksey and O’Malley [ 17 ] and developed by Levac et al. [ 18 ] and Peters et al. [ 19 ]. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) developed in 2020 by the Joanna Briggs Institute (JBI) were used to ensure reliability in the reporting of methodology (Additional file 1 ) [ 19 ].

Search strategy

According to the JBI Manuals for Evidence Synthesis, a three-step search strategy was adopted [ 19 ]. First, a preliminary search in PubMed was conducted based on the title, abstract, keywords, and index terms of articles to develop our search strategy. In the preliminary search, we used keywords such as “patients,” “nurse,” “IV therapy,” “monitoring,” “rate,” and “medication error.” The search results indicated that studies on medical devices and system-related factors were excluded. Therefore, we decided to exclude the keywords “patients” and “nurse” and focus on “IV therapy,” “monitoring,” “rate,” and “medication error” to comprehensively include studies on factors associated with rate control of infusion medications. Secondly, we used all identified keywords and index terms across all included databases following consultations with a research librarian at Yonsei University Medical Library to elaborate our search strategy. Four databases—PubMed, CINAHL, EMBASE, and Web of Science—were searched using the keywords, index terms, and a comprehensive list of keyword variations to identify relevant studies published before January 2023. The details of the search strategy are described in Additional file 2 . All database search results were exported into Endnote version 20. Finally, we manually searched the reference lists of the included articles identified from the database search. Furthermore, we manually searched two journals related to medication errors and patient safety, and Google Scholar to comprehensively identify the relevant literature. When performing a search on Google Scholar, keywords such as “medication,” “rate,” “IV therapy,” “intravenous administration,” and “medication error” were appropriately combined using search modifiers.

Eligibility criteria

Inclusion criteria were established according to the participants, concept, and context (PCC) framework recommended by the JBI manuals for scoping reviews [ 19 ]. The participants include patients receiving IV therapy, HCPs involved in administering IV medications, and experts from non-healthcare fields related to rate control of IV medications. The concepts were facilitators and barriers to rate control of IV medications, and the contexts were the environments or situations in which errors in rate control of IV medications occurred. While screening the literature identified by the three-step search based on the inclusion criteria, we refined the exclusion criteria through discussion among researchers. The exclusion criteria were as follows: (1) not available in English, (2) not an original article, (3) studies of medication errors in general, (4) not accessible, or (5) prescription error.

Study selection

Once duplicates were automatically removed through Endnote, two independent researchers assessed the eligibility of all articles by screening the titles and abstracts based on the inclusion and exclusion criteria. Studies identified via database searches were screened by GWR and YK and studies identified via other methods were screened by SBY and YK. Full-text articles were obtained either when the studies met the inclusion criteria or when more information was needed to assess eligibility and the researchers independently reviewed the full-text articles. In case of any disagreement in the study selection process, a consensus was reached through discussion among three researchers (GWR, SBY, and YK) and a senior researcher (JP).

Data extraction

Through consensus among the researchers, a form for data extraction was developed to extract appropriate information following the JBI manuals for scoping reviews [ 19 ]. The following data were collected from each study: author information, publication year, country, study design, study period, aims, participants or events (defined as the occurrences related to patient care focused on in the study), contexts, methods, errors related to the control of IV medications (observed results or intervention outcomes), error severity, facilitators, and barriers according to the NCC MERP criteria. Three researchers (GWR SBY, and YK) independently conducted data charting and completed the data extraction form through discussion.

Data synthesis

The general characteristics of included studies such as publication year, country, study design, and study period were analyzed using descriptive statistics to identify trends or patterns. The aims, participants, events, contexts, and methods of the included studies were classified into several categories through a research meeting including a senior researcher (JP) to summarize and analyze the characteristics of the included studies comprehensively. Attributes of errors associated with rate control of IV medications were analyzed and organized through consensus among researchers based on extracted data. Facilitators and barriers to rate control of IV medications were independently classified according to NCC MERP criteria by three researchers (GWR, SBY, and YK) and iteratively modified. Discrepancies were resolved by discussion and re-reading the articles, with the final decision made in consultation with the senior researcher (JP).

A total of 1211 studies were selected through a database search. After reviewing the titles and abstracts of the studies, 42 studies were considered for a detailed assessment by the three researchers. In particular, 2 were not available in English, 3 were not original articles, 24 were studies of medication error in general without details on rate control of IV medications, 2 were regarding prescription errors, and 1 was not accessible. Finally, 10 studies were identified through a database search. Additionally, 23 studies were identified from a manual search. Among the 23, 5 were not original articles, and 6 were studies on medication error in general. Finally, 12 studies were identified via other methods. Hence, 22 studies were included in the data analysis (Fig.  1 , Additional file 3 ).

PRISMA flow chart for literature selection

Characteristics of the studies

General characteristics.

Table 1 presents the general characteristics of the included studies. Two of the included studies had a publication year before 2000 [ 20 , 21 ], and more than half of the studies ( n  = 15) were published in 2010 and later. A majority of the included studies were conducted in Western countries ( n  = 15) [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ], four were conducted in Asia [ 20 , 37 , 38 , 39 ], two were conducted in Australia [ 21 , 40 ], and one was conducted in Egypt [ 2 ]. In terms of the study design, most studies were project studies ( n  = 7) [ 22 , 24 , 27 , 28 , 30 , 34 , 39 ] or prospective observational studies ( n  = 5) [ 2 , 20 , 29 , 32 , 40 ], followed by retrospective studies ( n  = 3) [ 21 , 25 , 35 ], qualitative or mixed-methods studies ( n  = 3) [ 23 , 26 , 33 ], and descriptive cross-sectional studies ( n  = 2) [ 36 , 38 ]. Additionally, there was one controlled pre-posttest study [ 37 ] and one simulation laboratory experiment study [ 31 ]. The study period also varied greatly from 2 days [ 32 ] to 6 years [ 25 ].

The aims of the included studies were divided into two main categories. First, 13 studies identified the current status, causes, and factors influencing errors that could occur in healthcare settings [ 2 , 20 , 21 , 23 , 25 , 26 , 29 , 32 , 33 , 35 , 36 , 38 , 40 ]. Among these, three studies were on errors that may occur in specific healthcare procedures, such as anesthesia [ 20 ], vascular access [ 21 ], and pediatric chemotherapy [ 25 ]. Additionally, three studies explored possible errors associated with specific settings and medications, such as an obstetric emergency ward [ 2 ], cardiac critical care units [ 38 ], and high-alert medications [ 36 ], and three studies investigated the errors associated with the overall IV medication preparation or administration [ 23 , 33 , 40 ]. Moreover, three studies aimed at identifying potential problems associated with the use of IV medication infusion devices [ 26 , 32 , 35 ], and one study was about errors in medication preparation and administration that could occur in a setting using a specific system connected to electronic medical records [ 29 ]. Second, nine studies described the procedure of developing interventions or identified the effect of interventions [ 22 , 24 , 27 , 28 , 30 , 31 , 34 , 37 , 39 ].

Participants and events

Participants in the 22 studies included HCPs such as nurses, doctors, pharmacists, and patients. Notably, four of these studies were only for nurses [ 31 , 37 , 38 , 40 ] and there was also one study involving only pharmacists [ 36 ]. Furthermore, there were five studies wherein people from various departments or roles participated [ 23 , 26 , 27 , 28 , 39 ]. There were three studies wherein the patients were participants, and two studies included both patients and medical staff [ 29 , 33 ].

Among the included studies, nine studies focused on errors in IV medication preparation and administration as events [ 23 , 26 , 30 , 32 , 33 , 34 , 37 , 38 , 40 ] and five studies focused on the administration process only [ 30 , 32 , 34 , 37 , 40 ]. Four studies focused on problems in the administration of all types of drugs including errors associated with rate control of IV medications [ 2 , 22 , 28 , 29 ]. Additionally, four studies focused on events that occurred with IV medication infusion devices [ 24 , 27 , 35 , 39 ], two studies explored the events that occurred during chemotherapy [ 22 , 25 ], and some analyzed events with problems in vascular access [ 21 ], iatrogenic events among neonates [ 28 ], and critical events in anesthesia cases [ 20 ].

Contexts and methods

The contexts can be largely divided into healthcare settings, including hospitals and laboratory settings. Three hospital-based studies were conducted in the entire hospital [ 20 , 22 , 24 ], eight studies were conducted at several hospitals, and the number of hospitals involved varied from 2 to 132 [ 23 , 26 , 32 , 33 , 34 , 35 , 38 , 40 ]. Furthermore, four studies were conducted in different departments within one hospital [ 29 , 30 , 37 , 39 ], three studies were conducted in only one department [ 2 , 27 , 28 ], two studies considered other healthcare settings and were not limited to hospitals [ 21 , 25 ], and one study was conducted in a simulation laboratory setting that enabled a realistic simulation of an ambulatory chemotherapy unit [ 31 ].

Specifically, seven out of the nine studies developed or implemented interventions based on interdisciplinary or multidisciplinary collaboration [ 22 , 24 , 28 , 30 , 34 , 37 , 39 ]. Two studies developed and identified the effectiveness of interventions that created an environment for nurses to improve performance and correct errors associated with medication administration [ 31 , 39 ], and two intervention studies were on error reporting methods or observation tools and the processes of addressing reported errors [ 28 , 30 ]. There were also a study on a pharmacist-led educational program for nurses [ 37 ], a comprehensive intervention from drug prescription to administration to reduce chemotherapy-related medication errors [ 22 ], infusion safety intervention bundles [ 34 ], the implementation of a smart IV pump equipped with failure mode and effects analysis (FMEA) [ 24 ], and a smart system to prevent pump programming errors [ 27 ].

Data collection methods were classified as a review of reported incidents [ 20 , 21 , 22 , 25 , 35 ], a review of medical charts [ 26 ], observations [ 23 , 29 , 30 , 31 , 32 , 33 , 34 , 37 , 40 ], follow-up on every pump alert [ 27 ], and self-reporting questionnaires or surveys [ 36 , 38 ]. Some studies utilized retrospective reviews of reported incidents and self-report questionnaires [ 39 ]. Also, in the study by Kandil et al., observation, nursing records review, and medical charts review were all used [ 2 ].

Attributes of errors associated with rate control of IV medications

Table 2 presents the attributes of errors related to rate control of IV medications in observed results or intervention outcomes, and error severity. Notably, 6 of 13 studies presenting observed results reported errors related to IV medication infusion devices among the rate control errors [ 20 , 25 , 32 , 33 , 35 , 36 ]. Additionally, four studies reported errors in bolus dose administration or IV push and flushing lines among IV rate errors [ 2 , 23 , 36 , 40 ]. Among the 13, nine studies reported error severity, and among these, three studies used NCC MERP ratings [ 25 , 32 , 33 ]. In four studies, error severity was reported by describing several cases in detail [ 2 , 21 , 23 , 25 ], and two studies reported no injuries or damages due to errors [ 26 , 29 ]. Among the nine studies that developed interventions and identified their effectiveness, four presented the frequency of incorrect rate errors as an outcome variable [ 28 , 30 , 34 , 37 ]. Moreover, two studies suggested compliance rates for intervention as outcome variables [ 24 , 31 ].

Among the nine project or experiment studies, three showed a decrease in error rate as a result of the intervention [ 28 , 31 , 34 ]. Three studies developed interventions to reduce rate errors but did not report the frequency or incidence of rate errors [ 22 , 24 , 27 ]. A study reported the frequency of rate errors only after the intervention; the effect of the intervention could not be identified [ 30 ]. Also, three studies showed the severity of errors related to rate control of IV medications [ 24 , 30 , 34 ], two used NCC MERP severity ratings [ 30 , 34 ], and one reported that all errors caused by smart IV pumps equipped with FMEA resulted in either temporary harm or no harm [ 24 ].

Facilitators and barriers to rate control of IV medications

Table 3 presents the facilitators and barriers related to rate control of IV medications according to the NCC MERP taxonomy based on the 22 included studies. Sub-categories of human factors were classified as knowledge deficit, performance deficit, miscalculation of dosage or infusion rate, and stress. The sub-category of design factor was device. System-related contributing factors were classified as frequent interruptions and distractions, inadequate training, poor assignment or placement of HCPs or inexperienced personnel, policies and procedures, and communication systems between HCPs [ 14 ].

Human factors

Among the barriers extracted from the 22 studies, 11 factors belonged to the “knowledge deficit,” “performance deficit,” “miscalculation of dosage or infusion rate,” and “stress (high-volume workload)” in this category. Half of these factors are related to the “performance deficit.” Barriers identified in two or more studies were tubing misplacement [ 24 , 35 ] and non-compliance with protocols and guidelines [ 2 , 25 ], all of which belonged to the “performance deficit.” Additionally, the high workload and environmental characteristics of the ICU, which corresponded to the “stress,” were also identified as barriers to rate control of IV medications [ 23 , 37 ].

Most factors in this category were related to IV medication infusion devices such as infusion pumps and smart pumps. In the study by Lyons et al., the use of devices, such as patient-controlled analgesia pumps and syringe drivers, was a facilitator of rate control of IV medications [ 33 ]. In addition to the use of these devices, the expansion of capabilities [ 26 ], monitoring programming [ 27 ], and standardization [ 22 ] were also facilitators. Unexpected equipment faults, a barrier, were identified in five studies [ 2 , 20 , 25 , 35 , 38 ]. Moreover, the complex design of the equipment [ 23 , 24 ] and incomplete drug libraries in smart pumps [ 33 , 35 ] were identified in two studies each. Factors such as the misassembly of an unfamiliar infusion pump [ 21 ] and smart pumps not connected to electronic systems [ 30 ] were also barriers.

Contributing factors (system related)

The factors belonging to the “frequent interruptions and distractions” in this category were all barriers. Specifically, running multiple infusions at once [ 24 , 27 ], air-in-line alarms, or cleaning air [ 24 ] were identified as barriers. Among the facilitators of the “training,” there were education and training on the use of smart IV pumps [ 24 ] and chemotherapy errors [ 22 ]. There are two factors in the “assignment or placement of a HCP or inexperienced personnel,” where ward-based pharmacists were facilitators [ 36 ], but nurses with less than 6 years of experience were barriers [ 40 ]. The sub-category with the most factors was “policies and procedures,” where the facilitators extracted in the four studies were double-checks through the process [ 22 , 24 , 28 , 36 ]. Among the barriers, two were related to keep-the-vein-open, which was identified in three studies [ 30 , 32 , 33 ]. The lack of automated infusion pumps [ 2 ], the absence of culture for use [ 32 , 33 ], and problems in the drug prescription process [ 33 ] were also identified as barriers. Communication with physicians in instances of doubt identified was the only identified facilitator in the “communication systems between HCPs” [ 28 ].

Resolutions for the barriers to rate control of IV medications

Table 4 presents the resolutions for the barriers to rate control of IV medications in the included studies. The suggested resolutions primarily belonged to the “contributing factors (system-related)” category. Resolutions in the “human factors” category were mainly related to the knowledge and performance of individual healthcare providers, and there were no studies proposing resolutions specifically addressing stress (high-volume workload), which is one of the barriers. Resolutions in the “design” category focused on the development [ 26 , 30 ], appropriate use [ 24 , 33 ], evaluation [ 26 ], improvement [ 24 , 26 , 30 ], and supply [ 23 ] of infusion pumps or smart pumps. Resolutions addressing aspects within the “contributing factors (system-related)” category can be classified into six main areas: interdisciplinary or inter-institution collaboration [ 23 , 25 , 28 , 30 , 34 , 35 , 36 , 37 ], training [ 24 , 37 , 40 ], implementation of policies or procedures [ 29 , 31 , 34 , 35 , 37 , 39 ], system improvement [ 25 , 30 , 32 ], creating a patient safety culture [ 25 , 37 , 38 ], and staffing [ 2 , 38 ].

This scoping review provides the most recent evidence on the attributes of errors, facilitators, and barriers related to rate control of IV medications. The major findings of this study were as follows: (1) there were a few intervention studies that were effective in decreasing the errors related to rate control of IV medications; (2) there was limited research focusing on the errors associated with IV medication infusion devices; (3) a few studies have systematically evaluated and analyzed the severity of errors associated with rate control of IV medications; and (4) the facilitators and barriers related to rate control of IV medications were identified by NCC MERP taxonomy as three categories (human factors, design, and system-related contributing factors).

Among the nine project or experiment studies, only two interventions showed statistically significant effectiveness for IV rate control [ 28 , 31 ]. Six studies did not report the specific statistical significance of the intervention [ 22 , 24 , 27 , 30 , 37 , 39 ], and one study found that the developed intervention had no statistically significant effect [ 34 ]. In another study, administration errors, including rate errors, increased in the experimental group and decreased in the control group [ 37 ]. IV rate control is a major process in medication administration that is comprehensively related to environmental and personal factors [ 3 , 41 ]. According to previous studies, interdisciplinary or multidisciplinary cooperation is associated with the improvement in patient safety and decreased medical errors [ 42 , 43 , 44 ]. Seven of the included studies were also project or experiment studies that developed interventions based on an interdisciplinary or multidisciplinary approach [ 22 , 24 , 28 , 30 , 34 , 37 , 39 ]. Additionally, an effective intervention was developed by a multidisciplinary care quality improvement team [ 28 ]. Therefore, it is crucial to develop effective interventions based on an interdisciplinary or multidisciplinary approach to establish practice guidelines with a high level of evidence related to IV rate control.

Of the 22 included studies, three identified potential problems associated with the use of IV medication infusion devices [ 26 , 32 , 35 ], and four described the application of interventions or explored the effects of the intervention developed to reduce errors that occur when using IV medication infusion devices [ 24 , 27 , 34 , 39 ]. IV medication infusion devices, such as infusion pumps and smart pumps, are widely used in healthcare environments and allow more rigorous control in the process of administering medications that are continuously infused [ 45 ]. Smart pumps are recognized as useful devices for providing safe and effective nursing care [ 15 ]. However, the use of IV medication infusion devices requires an approach different from traditional rate monitoring by counting the number of fluid drops falling into the drip chamber [ 9 ]. However, there exist many problems, such as bypassing the drug library, device maintenance, malfunction, tubing/connection, and programming in the use of IV medication infusion devices [ 32 , 35 ]. None of the four studies that described the application of interventions or explored the effects of the intervention demonstrated statistically significant effects. All four studies had no control group [ 24 , 27 , 34 , 39 ] and two studies had only post-test designs [ 24 , 27 ]. Therefore, further research needs to be conducted to analyze errors in rate control related to IV medication infusion devices and develop effective interventions.

A few studies have systematically evaluated and analyzed the severity of errors associated with rate control of IV medications. Among the 12 studies that reported the severity of errors associated with rate control of IV medications, five studies used NCC MERP, an internationally validated and reliable tool for assessing error severity, and one study used the Severity Assessment Code (SAC) developed by the New South Wales Health Department. Six studies did not use tools to assess error severity. The term “error severity” means the degree of potential or actual harm to patients [ 46 ]. Evaluating the severity of medication errors is a vital point in improving patient safety throughout the medication administration process. This evaluation allows for distinguishing errors based on their severity to establish the development of risk mitigation strategies focused on addressing errors with the great potential to harm patients [ 47 , 48 ]. Specifically, errors associated with rate control of IV medications were categorized as A to E on the NCC MERP and to groups 3 and 4 on the SAC. Additionally, errors associated with rate control of IV medications caused direct physical damage [ 2 , 21 ] and necessitated additional medication to prevent side effects or toxicity [ 23 ]. Therefore, as errors in rate control of IV medications are likely to cause actual or potential harm to the patient, research systematically evaluating and analyzing error severity should be conducted to provide the basis for developing effective risk reduction strategies in the rate control of IV medications.

Facilitators and barriers were identified as human, design, and system-related contributing factors. Among the human factors, “performance deficit” included failure to check equipment properly, tubing misplacement, inadequate monitoring, non-compliance with protocols and guidelines, and human handling errors with smart pumps. Nurses play a major role in drug administration; thus, their monitoring and practices related to IV medication infusion devices can influence patient health outcomes [ 3 , 49 ]. A major reason for the lack of monitoring was overwork, which was related to the complex working environment, work pressure, and high workload [ 3 , 11 , 49 ]. Moreover, two of the included studies identified high workload as a barrier to rate control of IV medications [ 23 , 37 ]. Therefore, to foster adequate monitoring of rate control of IV medications, a systematic approach to alleviating the complex working environment and work pressure should be considered.

Most facilitators and barriers in the devices category were related to IV medication infusion devices. In particular, expanding pump capabilities [ 26 ], monitoring pump programming [ 27 ], standardization [ 22 ], and using a pump [ 33 ] can facilitate rate control of IV medications. However, unexpected equipment faults are significant barriers, as identified in five studies among the included studies [ 2 , 20 , 25 , 35 , 38 ]. Moreover, the design [ 23 , 24 ], user-friendliness [ 21 ], connectivity to electronic systems [ 30 ], and completeness of drug libraries [ 33 , 35 ] are factors that can affect rate control of IV medications. Therefore, it is important to improve, monitor, and manage IV medication infusion devices so that they do not become barriers. Moreover, because rate errors caused by other factors can be prevented by devices, active utilization and systematic management of devices at the system level are required.

Although there are many benefits of infusion and smart pumps for reducing errors in rate control of IV medications, they cannot be used in all hospitals because of the limitation of medical resources. The standard infusion set, which is a device for controlling the rate of IV medication by a controller [ 9 ], is widely used in outpatient as well as inpatient settings [ 32 ]. Devices for monitoring the IV infusion rate, such as FIVA™ (FIVAMed Inc, Halifax, Canada) and DripAssist (Shift Labs Inc, Seattle, USA), which can continuously monitor flow rate and volume with any gravity drip set, have been commercialized [ 33 ]. However, they have not been widely used in hospitals. Therefore, developing novel IV infusion rate monitoring devices that are simple to use, can be used remotely, and are affordable for developing and underdeveloped countries can help nurses to reduce their workloads in monitoring IV infusion rates and thus maintain patient safety.

Most facilitators and barriers were system-related contributing factors, most of which belonged to the “policies and procedures.” In four studies, the absence of hospital policies or culture related to rate control of IV medications was identified as a barrier [ 2 , 30 , 32 , 33 ]. Medication errors related to incorrect rate control are problems that should be approached from macroscopic levels, such as via institutional policies and safety cultures. Therefore, large-scale research including more diverse departments and institutions needs to be conducted.

The second most common categories in system-related contributing factors were “frequent interruptions and distractions” and “training.” Although nurses experienced frequent interruptions and distributions during work, only one of the included studies was on interventions that were developed to create an environment with reduced interruptions [ 31 ]. Additionally, four studies found that education for nurses who are directly associated with medication administration is mandatory [ 22 , 23 , 24 , 36 ]. Therefore, education and a work environment for safety culture should be created to improve IV rate control.

Based on resolutions for barriers to rate control of IV medications, key groups relevant to rate control of IV medications include HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices. HCPs directly involved in the preparation and administration of IV medications need to enhance their knowledge of drugs, raise awareness for the importance of rate control of IV medications, and improve performance related to IV infusion device monitoring. Engineers specializing in IV medication infusion devices should develop these devices by integrating various information technologies used in clinical settings. Additionally, they should identify issues related to these devices and continuously enhance both software and hardware. Healthcare administrators play a crucial role in establishing and leading interdisciplinary or inter-institution collaborations. They should foster leadership, build a patient safety culture within the organization, and implement training, interventions, and policies for correct rate control of IV medications. Decreasing medication errors, including errors in IV rate control, is closely linked to the various key groups [ 50 , 51 , 52 , 53 ], and multidisciplinary collaboration is emphasized for quality care [ 54 , 55 , 56 , 57 ]. Therefore, each key group should perform its role and cooperate for appropriate IV rate control within a structured system.

This review has some limitations that should be considered. As there was no randomized controlled trial in this review, the causal relationship between wrong rate errors and their facilitators or barriers could not be determined. Moreover, only limited literature may have been included in this review because we included literature published in English and excluded gray literature. Since we did not evaluate the quality of the study, there may be a risk of bias in data collection and analysis. Despite these limitations, this study provides a meaningful assessment of published studies related to rate control of IV medications. This contribution will provide an important basis for new patient safety considerations in IV medication administration when determining future policies and device development.

The findings of this review suggest that further research is needed to be conducted to develop effective interventions to improve the practice of IV rate control. Moreover, given the rapid growth of technology in medical settings, research on IV medication infusion devices should be conducted. Additionally, to establish effective risk reduction strategies, it is necessary to systematically evaluate and analyze the severity of errors related to the rate control of IV medications. Several facilitators and barriers to rate control of IV medications were identified in this review to ensure patient safety and quality care, interventions and policy changes related to education and the work environment are required. Additionally, the development of a device capable of monitoring the flow of IV medication is necessary. This review will be useful for HCPs, hospital administrators, and engineers specializing in IV medication infusion devices to minimize errors in rate control of IV medications and improve patient safety.

Availability of data and materials

The corresponding author can provide the datasets that were utilized and/or examined during the present study upon reasonable request.

Abbreviations

Adverse event

Healthcare provider

Intensive care unit

Intravenous

Joanna Briggs Institute

The National Coordinating Council for Medication Error Reporting and Prevention

Cousins DD, Heath WM. The National Coordinating Council for medication error reporting and prevention: promoting patient safety and quality through innovation and leadership. Jt Comm J Qual Patient Saf. 2008;34(12):700–2. https://doi.org/10.1016/s1553-7250(08)34091-4 .

Article   PubMed   Google Scholar  

Kandil M, Sayyed T, Emarh M, Ellakwa H, Masood A. Medication errors in the obstetrics emergency ward in a low resource setting. J Matern Fetal Neonatal Med. 2012;25(8):1379–82. https://doi.org/10.3109/14767058.2011.636091 .

Parry AM, Barriball KL, While AE. Factors contributing to registered nurse medication administration error: a narrative review. Int J Nurs Stud. 2015;52(1):403–20. https://doi.org/10.1016/j.ijnurstu.2014.07.003 .

Vrbnjak D, Denieffe S, O’Gorman C, Pajnkihar M. Barriers to reporting medication errors and near misses among nurses: a systematic review. Int J Nurs Stud. 2016;63:162–78. https://doi.org/10.1016/j.ijnurstu.2016.08.019 .

Elliott RA, Camacho E, Jankovic D, Sculpher MJ, Faria R. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021;30(2):96–105. https://doi.org/10.1136/bmjqs-2019-010206 .

U.S. Food and Drug Administration (FDA) . Working to reduce medication errors [Internet]. U.S. Food and Drug Administration (FDA). 2019. Available from: https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors . Cited 27 Dec 2022

Institute of Medicine (US). Committee on quality of health care in America. In: Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academies Press (US); 2000. PMID: 25077248.

Google Scholar  

EscriváGracia J, Brage Serrano R, Fernández GJ. Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Serv Res. 2019;19(1):640. https://doi.org/10.1186/s12913-019-4481-7 .

Article   Google Scholar  

Park K, Lee J, Kim SY, Kim J, Kim I, Choi SP, et al. Infusion volume control and calculation using metronome and drop counter based intravenous infusion therapy helper. Int J Nurs Pract. 2013;19(3):257–64. https://doi.org/10.1111/ijn.12063 .

Marwitz KK, Giuliano KK, Su WT, Degnan D, Zink RJ, DeLaurentis P. High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. Res Social Adm Pharm. 2019;15(7):889–94. https://doi.org/10.1016/j.sapharm.2019.02.007 .

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933–8. https://doi.org/10.1136/bmjqs-2012-000946 .

Yoon J, Yug JS, Ki DY, Yoon JE, Kang SW, Chung EK. Characterization of medication errors in a medical intensive care unit of a university teaching hospital in South Korea. J Patient Saf. 2022;18(1):1–8. https://doi.org/10.1097/pts.0000000000000878 .

McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care. 2010;19(4):341–5. https://doi.org/10.1136/qshc.2008.029785 .

National Coordinating Council for Medication Error Reporting and Prevention. Taxonomy of medication errors. NCC MERP. 2001. Available from: https://www.nccmerp.org/taxonomy-medication-errors . Cited 27 Dec 2022

Moreira APA, Carvalho MF, Silva R, Marta CB, Fonseca ERD, Barbosa MTS. Handling errors in conventional and smart pump infusions: a systematic review with meta-analysis. Rev Esc Enferm USP. 2020;54:e03562. https://doi.org/10.1590/s1980-220x2018032603562 .

Sutherland A, Canobbio M, Clarke J, Randall M, Skelland T, Weston E. Incidence and prevalence of intravenous medication errors in the UK: a systematic review. Eur J Hosp Pharm. 2020;27(1):3–8. https://doi.org/10.1136/ejhpharm-2018-001624 .

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:1–9.

Peters MDJ, Marnie C, Tricco AC, Pollock D, Munn Z, Alexander L, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Implement. 2021;19(1):3–10. https://doi.org/10.1097/xeb.0000000000000277 .

Short TG, O’Regan A, Lew J, Oh TE. Critical incident reporting in an anaesthetic department quality assurance programme. Anaesthesia. 1993;48(1):3–7. https://doi.org/10.1111/j.1365-2044.1993.tb06781.x .

Article   CAS   PubMed   Google Scholar  

Singleton RJ, Webb RK, Ludbrook GL, Fox MA. The Australian incident monitoring study. Problems associated with vascular access: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):664–9. https://doi.org/10.1177/0310057x9302100531 .

Goldspiel BR, DeChristoforo R, Daniels CE. A continuous-improvement approach for reducing the number of chemotherapy-related medication errors. Am J Health Syst Pharm. 2000;15(57 Suppl 4):S4-9. https://doi.org/10.1093/ajhp/57.suppl_4.S4 . PMID: 11148943.

Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care. 2003;12(5):343–7. https://doi.org/10.1136/qhc.12.5.343 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Wetterneck TB, Skibinski KA, Roberts TL, Kleppin SM, Schroeder ME, Enloe M, et al. Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. Am J Health Syst Pharm. 2006;63(16):1528–38. https://doi.org/10.2146/ajhp050515 .

Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Cancer. 2007;110(1):186–95. https://doi.org/10.1002/cncr.22742 .

Nuckols TK, Bower AG, Paddock SM, Hilborne LH, Wallace P, Rothschild JM, et al. Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. J Gen Intern Med. 2008;23:41–5.

Evans RS, Carlson R, Johnson KV, Palmer BK, Lloyd JF. Enhanced notification of infusion pump programming errors. Stud Health Technol Inform. 2010;160(Pt 1):734–8 PMID: 20841783.

PubMed   Google Scholar  

Ligi I, Millet V, Sartor C, Jouve E, Tardieu S, Sambuc R, Simeoni U. Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. Pediatrics. 2010;126(6):e1461–8. https://doi.org/10.1542/peds.2009-2872 .

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, Duran-Garcia E, Durango-Limarquez MI, Hernández-Sampelayo P, Sanjurjo-Saez M. Prevalence of medication administration errors in two medical units with automated prescription and dispensing. J Am Med Inform Assoc. 2012;19(1):72–8. https://doi.org/10.1136/amiajnl-2011-000332 .

Ohashi K, Dykes P, McIntosh K, Buckley E, Wien M, Bates DW. Evaluation of intravenous medication errors with smart infusion pumps in an academic medical center. AMIA Annu Symp Proc. 2013;2013:1089–98 PMID: 24551395; PMCID: PMC3900131.

PubMed   PubMed Central   Google Scholar  

Prakash V, Koczmara C, Savage P, Trip K, Stewart J, McCurdie T, et al. Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting. BMJ Qual Saf. 2014;23(11):884–92. https://doi.org/10.1136/bmjqs-2013-002484 .

Article   PubMed   PubMed Central   Google Scholar  

Schnock KO, Dykes PC, Albert J, Ariosto D, Call R, Cameron C, et al. The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. BMJ Qual Saf. 2017;26(2):131–40. https://doi.org/10.1136/bmjqs-2015-004465 .

Lyons I, Furniss D, Blandford A, Chumbley G, Iacovides I, Wei L, et al. Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. BMJ Qual Saf. 2018;27(11):892–901. https://doi.org/10.1136/bmjqs-2017-007476 .

Schnock KO, Dykes PC, Albert J, Ariosto D, Cameron C, Carroll DL, et al. A multi-hospital before-after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. Drug Saf. 2018;41(6):591–602. https://doi.org/10.1007/s40264-018-0637-3 .

Taylor MA, Jones R. Risk of medication errors with infusion pumps: a study of 1,004 events from 132 hospitals across Pennsylvania. Patient Safety. 2019;1(2):60–9. https://doi.org/10.33940/biomed/2019.12.7 .

Schilling S, Koeck JA, Kontny U, Orlikowsky T, Erdmann H, Eisert A. High-alert medications for hospitalised paediatric patients - a two-step survey among paediatric clinical expert pharmacists in Germany. Pharmazie. 2022;77(6):207–15. https://doi.org/10.1691/ph.2022.12025 .

Nguyen HT, Pham HT, Vo DK, Nguyen TD, van den Heuvel ER, Haaijer-Ruskamp FM, Taxis K. The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study. BMJ Qual Saf. 2014;23(4):319–24. https://doi.org/10.1136/bmjqs-2013-002357 .

Bagheri-Nesami M, Esmaeili R, Tajari M. Intravenous medication administration errors and their causes in cardiac critical care units in Iran. Mater Sociomed. 2015;27(6):442–6. https://doi.org/10.5455/msm.2015.27.442-446 .

Tsang LF, Tsang WY, Yiu KC, Tang SK, Sham SYA. Using the PDSA cycle for the evaluation of pointing and calling implementation to reduce the rate of high-alert medication administration incidents in the United Christian Hospital of Hong Kong, China. J Patient Safety Qual Improv. 2017;5(3):577–83. https://doi.org/10.22038/PSJ.2017.9043 .

Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf. 2011;20(12):1027–34. https://doi.org/10.1136/bmjqs-2011-000089 .

Daker-White G, Hays R, McSharry J, Giles S, Cheraghi-Sohi S, Rhodes P, Sanders C. Blame the patient, blame the doctor or blame the system? A meta-synthesis of qualitative studies of patient safety in primary care. PLoS ONE. 2015;10(8):e0128329. https://doi.org/10.1371/journal.pone.0128329 .

Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014–8. https://doi.org/10.1001/archinte.163.17.2014 .

Lemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63(3):263–300. https://doi.org/10.1177/1077558706287003 .

O’Leary KJ, Buck R, Fligiel HM, Haviley C, Slade ME, Landler MP, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678–84. https://doi.org/10.1001/archinternmed.2011.128 .

Yu D, Obuseh M, DeLaurentis P. Quantifying the impact of infusion alerts and alarms on nursing workflows: a retrospective analysis. Appl Clin Inform. 2021;12(3):528–38. https://doi.org/10.1055/s-0041-1730031 . Epub 2021 Jun 30. PMID: 34192773; PMCID: PMC8245209.

Gates PJ, Baysari MT, Mumford V, Raban MZ, Westbrook JI. Standardising the classification of harm associated with medication errors: the harm associated with medication error classification (HAMEC). Drug Saf. 2019;42(8):931–9. https://doi.org/10.1007/s40264-019-00823-4 .

Assunção-Costa L, Ribeiro Pinto C, Ferreira Fernandes Machado J, Gomes Valli C, de PortelaFernandes Souza LE, Dean FB. Validation of a method to assess the severity of medication administration errors in Brazil: a study protocol. J Public Health Res. 2022;11(2):2022. https://doi.org/10.4081/jphr.2022.2623 .

Walsh EK, Hansen CR, Sahm LJ, Kearney PM, Doherty E, Bradley CP. Economic impact of medication error: a systematic review. Pharmacoepidemiol Drug Saf. 2017;26(5):481–97. https://doi.org/10.1002/pds.4188 .

Khalil H, Shahid M, Roughead L. Medication safety programs in primary care: a scoping review. JBI Database Syst Rev Implement Rep. 2017;15(10):2512–26. https://doi.org/10.11124/jbisrir-2017-003436 .

Atey TM, Peterson GM, Salahudeen MS, Bereznicki LR, Simpson T, Boland CM, et al. Impact of partnered pharmacist medication charting (PPMC) on medication discrepancies and errors: a pragmatic evaluation of an emergency department-based process redesign. Int J Environ Res Public Health. 2023;20(2):1452. https://doi.org/10.3390/ijerph20021452 .

Atey TM, Peterson GM, Salahudeen MS, Bereznicki LR, Wimmer BC. Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis. Emerg Med J. 2023;40(2):120–7. https://doi.org/10.1136/emermed-2021-211660 .

Hanifin R, Zielenski C. Reducing medication error through a collaborative committee structure: an effort to implement change in a community-based health system. Qual Manag Health Care. 2020;29(1):40–5. https://doi.org/10.1097/qmh.0000000000000240 .

Kirwan G, O’Leary A, Walsh C, Grimes T. Economic evaluation of a collaborative model of pharmaceutical care in an Irish hospital: cost-utility analysis. HRB Open Res. 2023;6:19. https://doi.org/10.12688/hrbopenres.13679.1 .

Billstein-Leber M, Carrillo CJD, Cassano AT, Moline K, Robertson JJ. ASHP guidelines on preventing medication errors in hospitals. Am J Health Syst Pharm. 2018;75(19):1493–517. https://doi.org/10.2146/ajhp170811 .

Lewis KA, Ricks TN, Rowin A, Ndlovu C, Goldstein L, McElvogue C. Does simulation training for acute care nurses improve patient safety outcomes: a systematic review to inform evidence-based practice. Worldviews Evid Based Nurs. 2019;16(5):389–96. https://doi.org/10.1111/wvn.12396 .

Mardani A, Griffiths P, Vaismoradi M. The role of the nurse in the management of medicines during transitional care: a systematic review. J Multidiscip Healthc. 2020;13:1347–61. https://doi.org/10.2147/jmdh.S276061 .

L Naseralallah D Stewart M Price V Paudyal 2023 Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review Int J Clin Pharm https://doi.org/10.1007/s11096-023-01626-5

Download references

This research was supported by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, the Ministry of Food and Drug Safety) (Project Number: RS-2020-KD000077) and Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (No. 2020R1A6A1A03041989). This work also supported by the Brain Korea 21 FOUR Project funded by National Research Foundation (NRF) of Korea, Yonsei University College of Nursing.

Author information

Authors and affiliations.

College of Nursing, Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Korea

Jeongok Park

University of Pennsylvania School of Nursing, Philadelphia, PA, USA

Sang Bin You

Department of Nursing, Hansei University, 30, Hanse-Ro, Gunpo-Si, 15852, Gyeonggi-Do, Korea

Gi Wook Ryu

College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea

Youngkyung Kim

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualization: JP; study design: JP; data collection: GWR, YK, SBY; data analysis: JP, GWR, YK, SBY; administration: JP; funding acquisition: JP; writing—original draft: JP, GWR, YK; writing—review and editing: JP, YK.

Corresponding authors

Correspondence to Gi Wook Ryu or Youngkyung Kim .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

Additional file 2:

Search queries and strategies by electronic databases.

Additional file 3:

Studies included in the data analysis.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Park, J., You, S.B., Ryu, G.W. et al. Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review. Syst Rev 12 , 230 (2023). https://doi.org/10.1186/s13643-023-02386-z

Download citation

Received : 15 May 2023

Accepted : 08 November 2023

Published : 13 December 2023

DOI : https://doi.org/10.1186/s13643-023-02386-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medication safety
• Patient safety
• Quality improvement
• Safety culture

Systematic Reviews

ISSN: 2046-4053

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

Research reveals language barriers limit effectiveness of cybersecurity resources

Online guidance that provides the most effective educational tools and reporting forms is only available in english.

The idea for Fawn Ngo's latest research came from a television interview.

Ngo, a University of South Florida criminologist, had spoken with a Vietnamese language network in California about her interest in better understanding how people become victims of cybercrime.

Afterward, she began receiving phone calls from viewers recounting their own experiences of victimization.

"Some of the stories were unfortunate and heartbreaking," said Ngo, an associate professor in the USF College of Behavioral and Community Sciences. "They made me wonder about the availability and accessibility of cybersecurity information and resources for non-English speakers. Upon investigating further, I discovered that such information and resources were either limited or nonexistent."

The result is what's believed to be the first study to explore the links among demographic characteristics, cyber hygiene practices and cyber victimization using a sample of limited English proficiency internet users.

Ngo is the lead author of an article, "Cyber Hygiene and Cyber Victimization Among Limited English Proficiency (LEP) Internet Users: A Mixed-Method Study," which just published in the journal Victims & Offenders . The article's co-authors are Katherine Holman, a USF graduate student and former Georgia state prosecutor, and Anurag Agarwal, professor of information systems, analytics and supply chain at Florida Gulf Coast University.

Their research, which focused on Spanish and Vietnamese speakers, led to two closely connected main takeaways:

• LEP Internet users share the same concern about cyber threats and the same desire for online safety as any other individual. However, they are constrained by a lack of culturally and linguistically appropriate resources, which also hampers accurate collection of cyber victimization data among vulnerable populations.
• Online guidance that provides the most effective educational tools and reporting forms is only available in English. The most notable example is the website for the Internet Crime Complaint Center, which serves as the FBI's primary apparatus for combatting cybercrime.

As a result, the study showed that many well-intentioned LEP users still engage in risky online behaviors like using unsecured networks and sharing passwords. For example, only 29 percent of the study's focus group participants avoided using public Wi-Fi over the previous 12 months, and only 17 percent said they had antivirus software installed on their digital devices.

Previous research cited in Ngo's paper has shown that underserved populations exhibit poorer cybersecurity knowledge and outcomes, most commonly in the form of computer viruses and hacked accounts, including social media accounts. Often, it's because they lack awareness and understanding and isn't a result of disinterest, Ngo said.

"According to cybersecurity experts, humans are the weakest link in the chain of cybersecurity," Ngo said. "If we want to secure our digital borders, we must ensure that every member in society, regardless of their language skills, is well-informed about the risks inherent in the cyber world."

The study's findings point to a need for providing cyber hygiene information and resources in multiple formats, including visual aids and audio guides, to accommodate diverse literacy levels within LEP communities, Ngo said. She added that further research is needed to address the current security gap and ensure equitable access to cybersecurity resources for all Internet users.

In the meantime, Ngo is preparing to launch a website with cybersecurity information and resources in different languages and a link to report victimization.

"It's my hope that cybersecurity information and resources will become as readily accessible in other languages as other vital information, such as information related to health and safety," Ngo said. "I also want LEP victims to be included in national data and statistics on cybercrime and their experiences accurately represented and addressed in cybersecurity initiatives."

• Communications
• Computers and Internet
• Information Technology
• Privacy Issues
• STEM Education
• Security and Defense
• World Development
• Cyber-bullying
• Cyber security standards
• Voice over IP
• Massively multiplayer online game
• National Security Agency
• World Wide Web
• Scientific method
• HTTP cookie

Story Source:

Materials provided by University of South Florida . Original written by John Dudley. Note: Content may be edited for style and length.

Journal Reference :

• Fawn T. Ngo, Anurag Agarwal, Katherine Holman. Cyber Hygiene and Cyber Victimization Among Limited English Proficiency (LEP) Internet Users: A Mixed-Method Study . Victims & Offenders , 2024; 1 DOI: 10.1080/15564886.2024.2329765

Cite This Page :

Explore More

• Australia On Track for Decades-Long Megadroughts
• Speed of Visual Perception Ranges Widely
• 3D Printed Replica of an Adult Human Ear
• Extremely Fast Wound Healing: New Treatment
• Micro-Lisa! Novel Nano-Scale Laser Writing
• Simple Brain-Computer Link: Gaming With Thoughts
• Clinical Reasoning: Chatbot Vs Physicians
• Understanding People Who Can't Visualize
• Illuminating Oxygen's Journey in the Brain
• DNA Study IDs Descendants of George Washington

Trending Topics

Strange & offbeat.