Physician lack of knowledge about interpreter value and use ranked highest priority (RPN 2418)

Description #

Among the nine failure modes rated by the expert panel, "Physician Knowledge and Skills" — the physician lacks knowledge of the value of using trained interpreters and how to work with them effectively — produced the highest aggregate Risk Priority Number (RPN = 2,418) and became the focus of subsequent discussion. Its component mean scores (each 1–10) were Occurrence 8.00, Importance 7.75, Detectability 6.50, and Intervention 6.00 (Table 1); RPN is the product of the four scores. This was the single failure mode that the panel added to the initial list. Higher RPN indicates a factor that is relatively more common, important, and harder to detect but easier to intervene on — i.e., a stronger candidate for targeted safety intervention.

"The failure mode 'Physician knowledge and skills: The physician lacks knowledge of the value of using trained interpreters and how to work with them effectively,' which the panel added, produced the highest RPN score and was the focus of considerable attention during subsequent discussion." (Maul, 2012, p. 333)

"The highest-priority factor was lack of knowledge regarding the value of using a trained interpreter and how to work with a trained interpreter effectively." (Maul, 2012, p. 328)

Methods Context #

What? #ⓘ

The observable: the aggregate Risk Priority Number (RPN) for each failure mode, a composite of four expert-rated 1–10 scales.

"The scoring worksheets were then used to derive individual and average risk priority numbers (RPNs) for each failure mode (RPN = Occurrence score ⫻ Importance score ⫻ Detection score ⫻ Intervention score)." (Maul, 2012, p. 332)

How? #ⓘ

Each panel member rated every failure mode on four 1–10 scales (Frequency of Occurrence, Impact/Importance, Detection, Intervention/Amenability) on a scoring worksheet, based on past experience, data where available, or expert intuition; mean scores were multiplied to yield the aggregate RPN reported in Table 1.

"When all major failure modes had been listed and clarified with concise definitions developed, HFMEA team members then scored each one according to four scales, providing ratings on the basis of past experience; data, if available; or the expert's intuition." (Maul, 2012, p. 331)

Who? #ⓘ

The national HFMEA expert panel of bilingual/partially bilingual physicians experienced in LEP care, rating from a general (cross-institution) rather than single-organization perspective.

"...an additional 8 experts, all of whom were bilingual or partially bilingual physicians who frequently cared for LEP patients." (Maul, 2012, p. 330)

Other Notes #

RPN here is a prioritization score derived from expert ratings, not a measured rate of patient harm (see qualifying caveats). Grounded in Table 1 (page 333).

Caveats #

• Small rarified LEP-expert panel from well-resourced settings with possible social-desirability bias The ratings come from a small, non-representative panel and may be biased in ways that limit generalization of the rankings. The raters were a "rarified universe" of experts on LEP care — all highly experienced, most practicing in facilities with well-staffed interpreter services — so they may have underemphasized issues that matter more in less expert or less well-resourced settings; the authors specifically note the "cost" and "wait time" rankings might have differed had the raters been clinicians in smaller or rural practices. As focus-group–style elicitation, results could also reflect social desirability — panelists reporting what they perceived to be the "right answer" rather than their true views (e.g., cost possibly ranked low because members know laws mandate language services regardless of cost). Finally, the panel comprised only practicing physicians (a typical HFMEA uses a multidisciplinary team), and a few members were fully fluent rather than partially bilingual and had to reason from a hypothetical partially-bilingual standpoint. These features make the specific RPN ordering — especially for cost and access/wait-time factors — fragile and setting-dependent.
• Risk rankings are subjective expert-panel priority scores, not measured patient-safety outcomes The Risk Priority Numbers (RPNs) and their ordering are composite scores derived entirely from expert opinion — panel members rating each failure mode on four 1–10 scales "on the basis of past experience; data, if available; or the expert's intuition" — rather than measured rates of miscommunication or patient harm. HFMEA is a deliberately proactive method chosen precisely because most institutions have no observed record of severe harm from inappropriate use of physician language skills; the authors note that "with luck, no known poor outcomes are available within the organization to study." The RPN rankings therefore quantify perceived priority for intervention, not empirically observed effect sizes or risk magnitudes, and should not be read as measured probabilities of harm.