Khoong, MD, MS, Division of General Internal Medicine, Department of Medicine at Zuckerberg San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Ave, 1M, San Francisco, CA 94122 ( Online: February 25, 2019. We recommend including English instructions and automated warnings regarding the use of machine translation.Īccepted for Publication: November 13, 2018.Ĭorresponding Author: Elaine C. Potential for harm can be minimized by using clear communication practices. Google Translate can be used to translate clinician-entered, patient-specific ED instructions for Spanish- and Chinese-speaking patients. Study limitations include assessment of only 2 languages (though our inclusion of Chinese is a strength, since non-European languages are often less accurately translated by machines) no assessment of translation readability and no comparison to human translators. While GT can supplement (not replace) written English instructions, machine-translated instructions should include a warning about potentially inaccurate translations.Ĭlinicians using GT can reduce potential harm by having patients read translations while receiving verbal instructions being vigilant about spelling and grammar and avoiding complicated grammar, medical jargon (eg, fingerstick), and colloquial English. In multivariable analyses, potential harm was associated in Spanish with a Flesch-Kincaid reading level higher than eighth grade (OR, 4.0 95% CI, 1.2-13.5) and follow-up instructions (OR, 3.5 95% CI, 1.2-10.2) and in Chinese with medical terminology (OR, 2.4 95% CI, 1.2-4.9), spelling or grammar anomalies (OR, 3.1 95% CI, 1.4-7.2), and colloquial English (OR, 5.9 95% CI, 1.4-24.7).ĭischarge instructions were translated by the new GT algorithm with higher accuracy and fewer seriously harmful inaccuracies than previously, 2 yet 2% of Spanish and 8% of Chinese sentence translations had potential for significant harm. Only spelling and grammar anomalies were associated with inaccurate translations in multivariable analyses: Spanish (odds ratio, 2.6 95% CI, 1.1-5.8) Chinese (OR, 2.6 95% CI, 1.3-5.0). Some errors were correct translations of errant English instructions, but overall, content was inaccurate owing to grammar or typographical errors ( Table 2) that would readily have been overlooked or understood by a reader of the English text. A minority of inaccurate translations had potential for clinically significant harm: in Spanish, 15 (28%) of 53 inaccuracies and 15 (2%) of 647 sentences in Chinese, 50 (40%) of 125 inaccuracies and 50 (8%) of 647 sentences. Overall, 594 (92%) and 522 (81%) sentences were accurately translated into Spanish and Chinese, respectively, by GT ( Table 1). The 100 sets of patient instructions contained 647 sentences. Variables with significance of P < .20 in bivariate analyses were used in multivariable analyses. We used logistic regression analyses stratified by language to assess associations between sentence characteristics and accuracy and/or harm. 6 For analyses, we used a binary variable (clinically significant/life-threatening vs clinically nonsignificant/no harm). Potential for harm from inaccurate translations was assessed by 2 clinicians (with a third adjudicating) using an established rating system: clinically nonsignificant, clinically significant, and life-threatening potential harm. A second translator reviewed back-translations deemed inaccurate to ensure these were not back-translator error. Two clinicians coded accuracy independently a third adjudicated disagreements. The primary outcome was sentence translation accuracy, assessed for overall content accuracy, not word-for-word accuracy, and coded as a binary outcome. Using GT we translated instructions into Spanish and Chinese, and then bilingual translators translated the text back into English. Content categories included explanation of diagnosis and/or results, follow-up instructions, medication instructions, return precautions, and greeting. 4 We analyzed each sentence by content category Flesch-Kincaid readability score use of medical jargon, 5 such as atypical use of normal words (eg, positive test result) or medical terminology and presence of nonstandard English (spelling or grammar errors, abbreviations, colloquial English, proper nouns). We abstracted 100 free-texted ED discharge instructions and oversampled for medication changes and common complaints.
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