Table 2. Real-Life Case Examples of Patient Safety Reports.

The following are real patient safety reports from one hospital in our study that illustrate key issues        related to language assistance.
Delays	1	Patient arrived in hemodialysis unit to do stat chest X-ray; patient had no  identification wristband and could not verify because he did not speak  English.
	2	Patient did not have a stress test because a Spanish interpreter was not available.  This delayed discharge for at least 24 hours.
	3	New patient arrived in infusion unit for first IP taxol appointment without  orders, consent, or a recent physician’s note. Patient did not speak English.  Interpreter and MD called. Delay in treatment resulted.
Medical Errors	4	Patient is Ethiopian speaking. On multiple occasions, there had been a failure to  provide an interpreter. She has been using family members to translate, and  they are not always available. This is unacceptable, as we have had issues with  medications (i.e., which to take, when) and I believe her worsening diabetes  is a direct result of my inability to have effective clinical meetings with her.
	5	Patient came down with his mother for a KUB film. Most exams that are  automatically scheduled are chest exams and so I performed one in error.  Usually I verify the exam with the patient but he was 11 years old and his  mother could not speak English. Immediately after I realized I had done the  wrong exam, I called the doctor and had him reorder the exam and I  performed the correct one.
	6	Informed consent obtained with no Spanish interpreter in emergency room;  patient did not understand the procedure when asked by interpreter.
	7	Patient was just admitted to the step-down unit from the Medical Intensive Care  Unit and was reported to be AOx3 (awake and alert) but Greek speaking  primarily. Patient was found on the floor, cardiac monitor attached, and foley  still attached to bed. Patient gestured she was going to the bathroom  unassisted.
	8	LEP patient arrived in the step-down unit s/p thoracic surgery. Hypertension in  OR and upon arrival to recovery room, 205/97. Patient with history of CVA in  past month, no past medical history or medication list available. Anesthesia  unable to give proper report or orders for hypertension management due to  lack of information.