Nataly Kelly: The value of a single word

If a picture is worth a thousand words, then what is a word worth? It seems difficult to quantify. Yet, 30 years ago, a Florida hospital was faced with that very question.

In 1980, 18 year old Willie Ramirez was admitted into the hospital. Spanish speaking family members trying to explain his symptoms said that they believed Willie was “intoxicado.” The hospital staff’s incorrect interpretation of the word led to one of the most tragic documented cases of medical error involving language differences.

Ramirez reported that he had a headache and felt dizzy. Due in great part to the fact that the word “intoxicado” was misinterpreted as “intoxicated,” Ramirez was diagnosed with an intentional drug overdose. The miscommunication led to a misdiagnosis, the wrong course of treatment, and eventually, to his quadriplegia. It also resulted in a malpractice settlement of $71m. It was later discovered that the symptoms were the result of an intracerebellar hemorrhage.

“Intoxicado” does not mean “intoxicated.” Rather, “intoxicado” refers to a state of poisoning, usually from ingesting something. “Intoxicación solar” means “sun poisoning.” “Intoxicación por plomo” means “lead poisoning.” “Intoxicación por alimentos” means “food poisoning.” In the case of Willie Ramirez, his family suspected that he had food poisoning because he had eaten an undercooked hamburger.

Yet, three decades after Willie Ramirez’s experience, the failure to address language barriers puts health care workers, their patients, and their facilities at risk. Just a few months ago, a California hospital was fined when a surgeon failed to provide an interpreter to Francisco Torres, a 72-year-old Spanish-speaking patient with a kidney tumor, before he consented to surgery. The surgeon removed the wrong kidney, and both the surgeon and hospital were sued for medical negligence.

Policymakers and health care professionals seek to provide patients and members of the public – including foreign-born citizens whose first language may not be English – with the highest quality health care possible. Yet, they often wrestle with the question, “Where will we find the money?” During a time of economic downturn, this question takes an even more prominent place at the forefront of decision-making. When budgets are slashed, services that are seen as unnecessary are eliminated.

But in health care, providing high-quality language services can actually reduce the overall costs of delivering services. Numerous studies – such as those published by Bernstein et al, Graham et al, Hampers et al, and others – show that providing language access can reduce dependency on emergency services in lieu of primary care, increase preventive care. Conversely, language barriers result in increased diagnostic testing costs and length of stay. As a report from the European Refugee Fund on the cost effectiveness of medical interpreting explains, “Language barriers can increase medical costs in two main ways: (1) they increase the risk of medical errors and complications of the disease; and (2) they can produce unnecessary costs.”

There are many ways to provide language services – and not all of them necessarily cost more money. Bilingual staff who can provide language-concordant care are often a viable option for overcoming language barriers – so long as their language skills are adequately screened. In addition, in countries like Australia and the United Kingdom, the government provides instant access to interpreters via telephone in order to lower the barrier to obtaining linguistic support whenever it is needed – perhaps, in part, because of the evidence that addressing these barriers reduces the total cost of health care over time.
And, language services are not just limited to spoken language. Sometimes, simply providing a translated form or patient education materials can make a difference between a patient following a treatment plan or presenting for the third time in a row in the emergency department, consuming valuable time and resources.

Furthermore, in many countries, laws require that language services be provided in health care settings. In the United Kingdom, the Human Rights Act 1998 and the Disability Discrimination Act 1995 highlight the importance of effective communication in hospital and GP practice settings, stating that wherever possible, “communications should be provided in languages and formats appropriate to the patient group.” In the United States, Title VI of the Civil Rights Act prevents discrimination on the basis of national origin, which includes those with limited English proficiency. A large number of states within the United States have also issued requirements for physicians to be trained in cultural competence, which typically includes training on language access.

What’s a word worth? It’s a question that has not been fully resolved, but one thing is certain – in healthcare settings, a single word, when misinterpreted, can dramatically alter the course of a patient’s life.

Nataly Kelly is the chief research officer at Common Sense Advisory, an independent research firm that focuses on language services and business globalization.

Competing interests:

Nataly Kelly is a full-time employee of Common Sense Advisory, whose revenue comes mostly from selling licenses to its research on language services.

Common Sense Advisory’s integrity policy is at