Translations for patient safety communication: Vital documents in the Hungarian health sector Ágnes Horváth Semmelweis University, Hungary A B ST RAC T Clear communication is essential to ensure patient safety and quality care, and written commu- nication and translated documents play a crucial role in their provision. Therefore, it is critical to create a list of vital documents and to ensure that they are language accessible for patients who do not speak the local language. The purpose of this study is to identify documents created within the Hungarian health sector, which contain health or legal information that may have important impli- cations for patients’ health, and are also essential for the provision of safe and high-quality health care, and which would also need to be made accessible to foreign patients. The study involved seven health professionals and a medical lawyer. Data was collected using qualitative methods, including semi-structured interviews and an online questionnaire. The data obtained was subjected to basic thematic and frequency analysis. The results show that health professionals consider six documents to be vital for Hungarian health care. In addition to this, a few other non-treatment related doc- uments were identified, whose translation would greatly contribute to effective communication with foreign patients. This study provides a solid basis for the creation of an official list of vital documents for the Hungarian healthcare system and can serve as a guide for other linguistic envi- ronments as well. Keywords: vital documents, medical translation, clear communication, patient safety, language assistance Prevajanje komunikacije za varnost pacientov: ključna zdravstvena dokumentacija v madžarskem zdravstvenem sistemu I Z V L EČ E K Za zagotavljanje pacientove varnosti in kvalitetne nege je jasna komunikacija ključnega pomena, pri čemer igrata pomembno vlogo pisna komunikacija in prevedeni dokumenti. Zato je ustvarjanje zdravstvene dokumentacije in zagotavljanje jezikovne dostopnosti teh dokumentov pacientom, ki ne govorijo lokalnega jezika, posebnega pomena. Namen pričujoče študije je identificirati doku- mente, ki so nastali v madžarskem zdravstvenem sistemu, ki vsebujejo zdravstvene in pravne infor- macije za zagotavljanje varne in visokokvalitetne zdravstvene nege in ki morajo biti dostopni tudi tujim pacientom. V študiji je sodelovalo sedem strokovnjakov s področja zdravstva ter odvetnik, specializiran za medicino. Za zbiranje podatkov so bile uporabljene kvalitativne metode, vključno s polstrukturiranim intervjujem in internetnim vprašalnikom. Dobljeni podatki so bili analizirani 5Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 z osnovno tematsko analizo in analizo pogostosti. Rezultati kažejo, da so strokovnjaki s področja zdravstva identificirali šest ključnih dokumentov za zdravstveno nego na Madžarskem, hkrati pa so identificirali še nekatere druge dokumente, ki se ne navezujejo na zdravljenje, za katere menijo, da bi njihov prevod veliko prispeval k učinkoviti komunikaciji s tujimi pacienti. Študija predsta- vlja trdno osnovo za ustvarjanje uradnega seznama zdravstvene dokumentacije za madžarski zdra- vstveni sistem in lahko služi kot vodilo tudi za druga jezikovna okolja. Ključne besede: ključna zdravstvena dokumentacija, medicinsko prevajanje, jasna komunikacija, varnost pacientov, jezikovna pomoč 1. Introduction Clear communication is essential for all patient‒provider interactions, regardless of the language spoken. However, when patients and providers speak different lan- guages, the complexity of communication increases significantly due to potential differences in language proficiency, cultural norms and medical terminology. In a multicultural and multilingual healthcare setting, this can result in miscommuni- cation, misinterpretation and the lack of communication (e.g., Harsham 1984; Co- hen et al. 2005; Flores 2005; HHS OMH 2013; Regenstein et al. 2013), which can then lead to inequalities in access to health services and a loss of people’s trust in the healthcare system. To overcome language barriers, research (Commonwealth of Massachusetts 2001; Park et al. 2005; AHQR 2010; The Joint Commission 2010; Federal Coordination 2011; Baruch and Walker 2013; HHS OMH 2013) suggests, among other things, the development of a Language Access Plan (LAP), if not at a national level, at least at an institutional level. In this document, the institution can specify how language assistance should be provided to patients who do not speak the local language. The document can thus include details on when to use inter- preters and who may act as an interpreter (e.g., qualified language mediators, lay interpreters (such as family members or friends), or in some cases, a minor child). Additionally, the document can outline the available forms of interpretation (e.g., in-house or remote). Regarding translations, an LAP can define which documents need to be translated, into which foreign language(s), and who can provide translations. Through the trans- lation of written documents, healthcare institutions ensure that patients have access to written information which enables them to use the healthcare services available, to better understand their own medical conditions and to make informed decisions about their health. Making documents language accessible for everyone improves the health institution’s cultural competency, shows respect for the patient, deepens the provider‒patient relationship and increases patient satisfaction (Flores 2005; Park et al. 2005; AHQR 2010; Baruch and Walker 2013; Regenstein et al. 2013). 6 Ágnes Horváth: Translations for patient safety communication However, the limited amount of financial and human resources makes it difficult to translate all the documents in use, and thus the U.S. Department of Health and Hu- man Services (HHS) (2003) recommends the collection and translation of the so- called vital documents. According to the HHS (2003), “whether or not a document (or the information it solicits) is ‘vital’ may depend on the importance of the program, information, encounter, or service involved, and the consequence to the LEP person if the information in question is not provided accurately or in a timely manner” (para C). Vital documents are thus those that contain legal or other information that has important consequences if relied upon; that draw attention to patients’ rights and available hospital services, programmes and activities; that contain information rel- evant to the provision of safe and high-quality health care; or that are important or commonly used in the target department or hospital. The documents and other texts that may be considered vital include (The Guide n.d.; Flores 2005; Wu et al. 2007; AHRQ 2010; Hablamos Juntos 2012): • signage, directions and notices about the availability of interpreter services; • administrative and legally binding documents (consent forms, client rights, and responsibilities, privacy notices, complaint forms, emergency room release and discharge forms, documents establishing and maintaining eligibility for services, and notices of non-coverage); • clinical information (prevention and treatment instructions; what to do before, during, and after a procedure or treatment; how to take medicine; and how to perform routine self-care or self-monitoring; medication labels); • education, health prevention and promotional materials (brochures, fact sheets, pamphlets, promotional flyers and posters, health advisories, and other materials that support treatment programmes (e.g., for chronic disease or mental health); and • prevention activities (e.g., cancer or high blood pressure screenings). Many researchers believe that it would be best if these vital documents were translated into patients’ mother tongues, but if this is not possible, they should at least be provid- ed in the so-called threshold languages (HHS 2003; California Health Care Safety Net Institute 2005; HHS OMH 2005; Wu et al. 2007; The Joint Commission 2010; Prata 2015; García-Izquierdo and Montalt 2022). What actually constitutes a threshold lan- guage should be calculated after assessing the language needs of patients and identify- ing the languages that are most frequently encountered in a specific healthcare context (HHS 2003). Translating vital documents, monitoring the quality of written commu- nication, making necessary improvements to existing translations or introducing new standards are all essential for clear communication and patient safety (Lindholm et al. 2012; Baruch and Walker 2013). In order to ensure that the translations of these key 7Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 documents are of a high standard, it is recommended that translation guides are pro- duced to facilitate the translation process and help with quality control (House 1997; Nord 1997; HHS 2003; Hablamos Juntos 2012). Today, there is no regulation in Hungary that makes it mandatory for any healthcare document to be translated for non-Hungarian-speaking patients, although there are certain acts and decrees that consider oral communication and the role of interpret- ers. The Ministry Decree 24/1986 (26.VI.) and Article 12(1) – (3) of Act CCXL of 2013, for example, state that people who do not speak Hungarian have the right to free interpretation and translation services, but only in criminal proceedings. According to Act CLIV of 1997 on Health Care, “the patient has the right to be informed in a manner which they understand, taking into account their age, education, knowledge, state of mind and their wishes in this respect, and to be provided with an interpreter or sign language interpreter if necessary and possible.” (Magyar Közlöny 1997, Article 8). In the case of language barriers, the interpreter has to be provided by the health- care provider. With regard to mandatory translations, the Ministry of Health Decree 30/2005 (VIII. 2) states that certain information must be provided in Hungarian only on the labels and package leaflets of medicinal products for human use. 2. Literature review Two studies report on the availability of documents in foreign languages in the Hun- garian health sector. First, Gellér et al. (2012) published a handbook Access to the Healthcare System for Third-country Nationals, in which the authors noted that the use of translated documents was not common in health care ten years ago (i.e., in 2012). In their view, the problem stemmed from the fact that public institutions lacked the fi- nancial resources to provide this language service. Second, Horváth’s (2022) research aimed to explore the strategies and norms of Hungarian health professionals when they inform their foreign patients, especially in written form. A questionnaire survey, completed by 110 health professionals across the country (96 from public institu- tions and 14 from private institutions), showed that Hungarian health professionals encounter patients of many nationalities and mother tongues in the course of their work, as shown in Figure 1. It is important to note that the study was conducted in September and October, 2021 before the outbreak of the war in Ukraine. The per- centages in Figure 1 represent the proportion of respondents who said they had en- countered patients of the given nationality. As a supplement, Table 1 shows the Hun- garian Central Statistical Office’s (Központi Statisztikai Hivatal, KSH) data on foreign nationals residing in Hungary over the last ten years, as well as the statistics before Hungary joined the European Union in 2004. 8 Ágnes Horváth: Translations for patient safety communication Table 1. Foreign citizens residing in Hungary (based on KSH 2023). Continent, country 2004 2012 2022 Europe 110,915 110,122 131,431 including:       Romania 55,676 41,596 16,601 Ukraine 13,096 11,894 30,707 Germany 7,393 15,834 19,747 Russia 2,244 2,864 4,980 Slovakia 2,472 6,705 16,040 Asia 14,715 24,733 55,000 including: China 6,790 10,114 17,685 America 2,535 4,713 7,454 including: US 1,703 3,060 3,051 Africa 1,455 3,284 8,028 Australia and Oceania 489 509 612 In sum: 130,109 143,361 202,525 Table 1 summarizes the rise in number and distribution of foreign citizens residing in Hungary, with a 41% increase observed between 2012 and 2022, and a 56% increase compared to pre-EU accession. This growing national diversity is evident in the di- verse patient population of Hungarian hospitals, as illustrated in Figure 1. Figure 1. Percentage of foreign nationals in Hungarian hospitals (based on Horváth 2022, 82). Other 24% Serbian 3% Spanish 2% Italian 3% Arabic 3% Russian 4% Ukrainian 7% Romanian 10% Chinese 11% British and American 12% German and Austrian 21% 9Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 Respondents were also asked about their own perception of the level of English pro- ficiency of the foreign patients they treat. They could choose more than one of the four response options but were also given the opportunity to formulate their own response, as shown in Figure 2. In the other category, it was reported that the language skills of their patients varied greatly, with some speaking little Hungarian. Figure 2. Foreign patients’ proficiency in English in Hungarian clinics as seen by health professionals (based on Horváth 2022, 83). It is important to note that Figure 2 reflects the opinions of health professionals who are not language experts. Although a B2 level language exam has been required to obtain a diploma in higher education in Hungary since January 1, 2013, Hungary’s overall proficiency in foreign languages, particularly English, is considered lower than in many other EU countries. According to a 2016 Eurostat survey on language skills, only 42% of Hungarians reported being able to speak at least one foreign language, which is far below the EU average of 65% (European Commission 2021). However, language proficiency can vary depending on factors such as age, education level, and location within a country. It should also be noted that it is not known how the health professionals ensured that patients understood what was said. Regarding the documents available to non-Hungarian speaking patients in a foreign language at the workplace of the health professionals surveyed, Horváth’s (2022) re- search was limited to the informed consent forms (ICFs) that each patient has to sign before any invasive medical procedure. Respondents were invited to provide longer 3% 3% 27% 56% 29% 0% 10% 20% 30% 40% 50% 60% Other They do not speak English at all. They only understand a few words, so communication is very difficult. Their English is sufficient, they can understand the main information. The majority can communicate well in English, they understand the content of information leaflets and consent forms. 10 Ágnes Horváth: Translations for patient safety communication answers to an open-ended question. Figure 3 shows the responses of 80 out of the 110 health professionals, who responded to the questionnaire. Given that only 72.7% of participants responded, it can be assumed that 30 participants chose not to answer the question because they did not consider it relevant, or they could not give a positive and substantial response to the question of what kind of translated ICFs they had. In the ‘other’ response option (2%), paramedics reported that in their case the patients give oral consent, so they did not work with written translations. Figure 3. ICFs available in any language other than Hungarian (based on Horváth 2022, 95). The primary objective of the present study was to explore which documents used in the Hungarian healthcare system are considered by health professionals to be vital for patient safety. A secondary objective of the study was to expand the category of vital documents by eliciting health professionals’ views on which other documents – although neither vital nor even treatment-related – contribute greatly to effective communication between the provider and foreign patient, leading to an improvement in the overall quality of healthcare services; and for which reason, the translation of such documents would also be encouraged. Although I was primarily interested in recording the perspective of healthcare pro- viders, I also consulted a medical lawyer. To achieve the objectives of the study, an online questionnaire was designed and sent to health professionals. In addition to this, semi-structured interviews with representatives of clinics at a medical university as well as with a medical lawyer were conducted. With the interviews, I attempted to 2% 1% 1% 13% 24% 59% 0% 10% 20% 30% 40% 50% 60% 70% other We have ICFs in English, French and Spanish. We have ICFs in English, German and Romanian. We have some/all in both English and German. We have some/all but only in English We have no translations or I don't know about it. 11Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 obtain a list of the key healthcare documents in the Hungarian context and to estab- lish if and how they differ from the similar list in the United States. Due to the distinct healthcare systems in the two countries (the United States is predominantly a private system with private entities providing healthcare services, while Hungary’s healthcare system is primarily a public system with government-provided healthcare services funded through taxes), it was anticipated that Hungarian vital documents would not include insurance or payment-related records. I conducted the interviews with health professionals and a medical lawyer, i.e. two parties that approach the problem from different angles, with the hope that I would thus get a more complex picture by aggregating the results. Health professionals from six different departments were interviewed. I expected them to identify a relatively large variety of vital documents based on their different medical or health science studies and their hospitals experience. The medical lawyer, however, was expected to identify vital documents which contain information that is crucial for the rights and safety of patients and may lead to significant legal implications if relied upon or ignored, and that hold significant importance in legal proceedings. After collecting interview responses, I formulated questions for the quantitative research, which con- sisted of an online questionnaire with multiple-choice questions, to which 108 health professionals responded. In this article, I report on the study which aimed to address the following research questions: 1) What are the documents used in health care that are vital for the success of a treatment and for the health of the patient?; 2) What documents with direct rel- evance to patients’ rights need to be translated?; 3) What are the non-treatment-re- lated documents that are not vital but contribute highly to the quality of healthcare services and therefore need to be translated? 3. Methods 3.1 Participants and setting Health professionals in 20 clinics affiliated with Semmelweis University, a prestigious medical university in Hungary, were contacted, but only six clinics responded and were available for appointments. The semi-structured interviews were conducted in Hungarian with six doctors and one health professional who holds a degree in health sciences. During one interview, two doctors from a single clinic participated. In order to maintain anonymity and confidentiality regarding the sensitive issue of commu- nication with foreign patients, the names of the clinics are not disclosed. The med- ical lawyer interviewed for the study held both a medical and a law degree and was 12 Ágnes Horváth: Translations for patient safety communication contacted through the university. Due to the COVID-19 pandemic, the interview was conducted via Zoom Meeting, a videoconferencing platform. After the completion of the interviews, an online questionnaire on Google Forms was sent out to health professionals, such as the heads of the medical school’s clinics, alumni members of the university, current and graduate medical translation students. Snowball sampling was used, and the questionnaire was posted on health profession- als’ community forums to explore what they consider to be vital documents. Finally, a total of 108 participants from 39 different departments completed and returned the questionnaire. The departments with the highest number of completed question- naires were obstetrics and gynaecology, anaesthesiology intensive care, paediatrics, and surgery. The respondents were not asked to identify the name of the hospital and the city in which they worked, so that they could stay completely anonymous. Their gender and age were irrelevant for the study, and thus were not collected. 3.2 Instruments of data collection and methods of analysis To gather insights into which documents are considered vital in Hungarian health care, semi-structured interviews were conducted between December 2021 and May 2022, using Zoom Meetings, a videoconferencing software platform, due to the COV- ID-19 pandemic. The interviews lasted between 20 to 60 minutes. The purpose of the interviews with the health professionals was to explore how Hungarian healthcare institutions communicate with foreign patients in terms of written texts. The inter- views consisted of eight pre-prepared guiding questions, including two questions spe- cifically focusing on vital documents and other written texts that would help health professionals communicate with foreign patients. In contrast, the interview with the medical lawyer was brief, lasting approximately 30 minutes, and focused only on the question of which documents they considered vital to patients’ rights. The answers received were subjected to basic thematic analysis without using coding. An online questionnaire on vital documents was also used to collect the opinions of health professionals from different parts of the country on the issue. The study was conducted between April and May 2022. The language of the questionnaire was Hun- garian, allowing health professionals to express themselves freely. The questionnaire’s aim was to identify which healthcare documents, according to healthcare providers, are vital for patient safety in Hungary. Data collection was done using the snowball technique. The questionnaire was composed of three open-ended questions, two of them on vital documents. These two addressed 1) which healthcare documents pro- fessionals consider vital for the success of treatment and the health of the patient, 13Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 and 2) which documents they consider vital for patient rights. Frequency analysis (Oppenheim 2000) was performed on the data thus obtained. In order to broaden the category of vital documents, the third question of the questionnaire sought to iden- tify the non-treatment-related documents that professionals consider important for effective communication with foreign patients, and that would therefore be useful to translate. An English translation of the questionnaire can be found in the Appendix. 4. Results The following section first contains the findings obtained from the semi-structured interviews conducted with representatives from the six clinics and the medical lawyer, followed by the data on vital documents gathered through an online questionnaire completed by the Hungarian health professionals. 4.1 Results of the semi-structured interviews In their responses to the questions “From a patient’s point of view, which medical doc- uments would your department need to translate?” and “What medical documents, texts, and signs would need to be translated for the daily successful functioning of the department and for effective communication?”, the interviewed representatives of the clinics from the medical university identified 13 different documents. The most frequently mentioned documents included various consent forms (general consent form, consent form for invasive and non-invasive procedures), patient information sheets, discharge papers (especially the summary section) and house rules. They also emphasized the importance of therapeutic indications (diet, wound care, physiother- apy) and patient education materials. Additionally, they believed that clear informa- tion on medication rules and follow-up appointments was needed in a language that is understood by foreign patients. The hospital’s website, brochures on available ser- vices, and wayfinding signs were also mentioned as items that would need to be avail- able in other languages as well. During the interviews, the respondents tended to blur the line between the first two questions and simply listed documents that they believed were essential to improve their communication with foreign patients. The analysis of their responses led me to the conclusion that it was necessary to rephrase these questions in the online ques- tionnaire. In the interview with the medical lawyer, I specifically inquired about the documents that are vital in the healthcare system from a patient rights perspective. In response, they identified the following documents: informed consent forms, patient information sheets, discharge papers, in particular discharge summaries, the results 14 Ágnes Horváth: Translations for patient safety communication of any laboratory or imaging tests, autopsy notes and clinical notes from outpatient clinics as key to patients exercising their right to information and making informed decisions about their health. 4.2 Vital documents for patient safety In this section, I first clarify how the outcome of my interviews with clinic repre- sentatives and the medical lawyer influenced the design of the online questionnaire and provided guidance on how to construct the multiple-choice questions. I then provide the responses to each question. According to the U.S. Health and Human Services, HHS (2003) vital documents are defined as follows: “whether or not a document (or the information it solicits) is ‘vital’ may depend on the importance of the program, information, encounter, or service involved, and the consequence to the LEP person if the information in question is not provided accurately or in a timely manner” (para C). Given the complexity of this definition, it was thought appropriate to approach vital documents as documents that are key to the success of treatment and key to the suc- cess of the health of the patient. By this, it is meant that patients are aware of their health status, know what treatment they are about to receive, are aware of the benefits and risks, and understand and follow their doctor’s instructions, for example regard- ing medication or post-operative care. On the other hand, vital documents are under- stood as documents that are meant to ensure that patients can exercise their right to information, have a clearer picture of their health and actively participate in decisions concerning their own health. As the term vital documents does not exist in Hungarian medical discourse, the questions in the questionnaire needed to be clearer and more explanatory. I there- fore avoided the Hungarian equivalent of the word “vital” (“vitális”) and used the adjective “key” (“kulcsfontosságú”) instead. For the purpose of the questionnaire, I have broken down the concept of vital documents into: (1) documents that are key to the success of treatment and the health of the patient, and (2) documents that are key to patient rights. The first question that participants had to answer was “In your opinion, which doc- uments (e.g., final reports, results, patient information sheets, consent forms) play a key role in the SUCCESS OF THE TREATMENT and the PATIENT’S HEALTH, and should therefore be translated into a foreign language for foreign patients?” The re- sponses were analysed using the frequency distribution, and the results are presented in Figures 4 and 5. 15Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 Figure 4. Vital documents for the success of the treatment and the patient’s health. Figure 4 shows the documents most frequently identified by health professionals as vital: 73% of the respondents stated that discharge papers, in particular discharge summaries, are vital documents for the success of treatment and the health of the patient. As the second most important document, consent forms are listed, includ- ing general consent forms and consent forms for surgery, examination, anaesthesia or blood transfusion. Next are the patient information sheets, which describe what a patient can expect before, during and after a medical procedure. These documents usually differ from the consent forms in Hungary, which patients read and sign before the procedure. Radiology, laboratory and pathology results were considered vital documents by 43% of the respondents. The documents listed so far were all examples of key documents mentioned in the questionnaire, which possibly affect- ed the respondents’ answers, however, some of respondents also named additional key documents that were not provided in the questionnaire. The outpatient clinical note was one of these, which was considered a vital document by 20% of respond- ents. There were a few participants who stressed the importance of providing in- formation to patients about their post-operative care, including information about available rehabilitation programmes, dietary restrictions or necessary follow-up examinations. In Figure 5 the votes cast for each document are shown as a proportion of the total responses. In the other category, respondents named documents including hospital 4% 20% 43% 60% 56% 73% 0% 10% 20% 30% 40% 50% 60% 70% 80% information on postoperative care outpatient clinical notes radiological, histopathological and laboratory results consent form patient information sheet discharge paper and summary 16 Ágnes Horváth: Translations for patient safety communication admission and discharge forms, wayfinding signs, charts, drawings to help with pa- tient communication, referrals, medical histories, patient charts, house rules, treat- ment plans and quotations. As the questionnaire contained open-ended questions, participants had the chance to express their views in more detail. For example, one respondent stressed that while patients need to be informed in writing about their health condition or about an upcoming intervention, it is even more important for the patient’s health or recovery that they understand the written text. This was a clear ref- erence to the literacy and health literacy levels of patients, which is explicitly recom- mended to be taken into account when making translations (The Joint Commission 2010; Baruch and Walker 2013), and a topic that has been extensively researched (e.g., Hanrahan et al. 2015; Brelsford et al. 2018; Kamaara et al. 2020). A different respond- ent noted that translations are not necessarily needed for the success of treatment and the health of the patient, but rather, signs, cards and drawings that can establish communication with particular patients, such as those who are intubated or unable to communicate orally. The second question asked the participants to answer the following: “In your opin- ion, which documents (e.g., final reports, results, patient information sheets, consent forms) are key from a PATIENTS’ RIGHTS point of view and therefore should be translated into a foreign language for foreign patients? There may be an overlap in your answer to the previous question.” other 8% outpatient clinical notes 19% results 14% consent form 19% patient information sheet 17% discharge paper and summary 23% Figure 5. Percentage of vital documents for the success of the treatment and the patient’s health. 17Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 Figure 6. Vital documents for patients’ rights. As presented in Figure 6, the largest percentage of respondents ranked consent forms as a key document for patients’ rights. A high proportion of respondents also strongly agreed that discharge papers, discharge summaries and patient information sheets are key documents for patients’ rights. Additionally, one in three health professionals considered radiology, laboratory and pathology results as key documents. There was a considerable overlap in the answers to the second and first questions, but some respondents also listed other documents, such as house rules and outpatient clinical notes, which they also considered to be key to patients’ rights. Below is a breakdown of what percentage of total responses each document received (Figure 7). As shown in Figure 7, patient information sheets, consent forms and discharge pa- pers, in particular their discharge summary, account for 78% of the responses. The re- sults of examinations obtained 11% of the responses, while among the other category documents such as refusal of medical treatment, documentation of discharge against medical advice, patient chart, treatment plan, quality management system documen- tation, authorizations, website and wayfinding signs were suggested. The overlap in the responses to the two questions (Figure 5, Figure 7) indicates a consensus among the respondents. Consent forms, patient information sheets and discharge papers, in- cluding the summary, emerged as the top-ranked documents from the patients’ rights standpoint, aligning with their importance for treatment success. This suggests that healthcare professionals recognize the significance of ensuring these documents and safeguarding patients’ rights through translated consent forms. 8% 4% 33% 88% 68% 61% 0% 20% 40% 60% 80% 100% outpatient clinical notes house rules radiological, histopathological and laboratory results consent form patient information sheet discharge paper and summary 18 Ágnes Horváth: Translations for patient safety communication If the results of the two questions are aggregated, a list of vital documents used in Hungarian health care is obtained, as shown in Figure 8. In addition to these doc- uments, several other documents were mentioned, but none of them was named by more than one respondent. Figure 8. Vital documents for patient safety. 2% 2% 14% 38% 74% 62% 67% 0% 10% 20% 30% 40% 50% 60% 70% 80% house rules information on postoperative care outpatient clinical notes radiological, histopathological and laboratory results consent form patient information sheet discharge paper and summary other 7% discharge paper and summary 22% consent form 32% patient information sheet 24% results 11% Figure 7. Percentage of vital documents for patients’ rights. 19Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 4.3 Other translations that can help improve the quality of health care The research’s secondary objective was to expand the category of vital documents by eliciting documents that are not vital, or even related to treatment, but which contrib- ute to effective communication between the provider and foreign patient, and thus to the overall quality of health services to such an extent that their translation is rec- ommended. Data was collected through the third and final questions of the online questionnaire on vital documents. Participants were asked the following: “In your opinion, which non-treatment related GENERAL INFORMATION and GUIDING DOCUMENTS (e.g.: house rules, website, wayfinding signs, clinic map, parking in- formation) should be translated into a foreign language for foreign patients?” The results are presented in Figure 9. Figure 9. Non-treatment related documents to be translated. As shown in Figure 9, more than 50% of health professionals considered that wayfin- ding signs, maps of the hospital and departments, the hospital’s website and hospital department rules (e.g., the schedule of ward rounds, what to take to hospital upon admission, visiting hours, what food can be brought to the hospital) are documents that should be accessible in translation, as they help make everyday communication easier and contribute to the quality of care. Besides these factors, the participants felt that a useful note for foreign patients would be information on parking facilities. It was also suggested by health professionals that it would be helpful if visiting rules are made available in translation. Many respondents wrote that foreign patients should 5% 10% 8% 39% 56% 52% 60% 62% 0% 10% 20% 30% 40% 50% 60% 70% information on finances contacts visiting rules parking facilities hospital/department map wayfinding signs webpage house rules 20 Ágnes Horváth: Translations for patient safety communication be provided with different contact details, including doctors, GPs, pharmacies, inter- preters, emergency services, patient representation and contact details for complain- ants. Several respondents also mentioned that financial information should be made available in translation. Such documents include, for example, a list of fees for exam- inations, information on payment options for EU and non-EU citizens, the process of invoice payment, the address of the bursar’s office or information on guarantees. Beyond the documents shown in Figure 9, other general information documents and wayfinding signs were also mentioned by health professionals as candidates for trans- lation. These included the location and times of the appointments and on-call servic- es, contact details for making appointments, leaflets and wall stickers for wheelchair accessibility, mask regulations, or a sign saying that a lift is not working and where to find another one. Respondents also mentioned some patient education materials, such as information on the duties of the GP on call, a short summary of the department’s operations, general information on the Hungarian health system, general information on diseases, information on outpatient care and the patient-admission procedure, what documents are required for patient admission, information on how to make an appointment at various clinics, how to request a referral, how foreign nationals can access the various health services and programmes, and lastly, information on the legal and social security administration possibilities and procedures for patient care. 5. Discussion The main aim of this study was to investigate, on the one hand, which documents used in Hungarian health care are perceived by health professionals as vital docu- ments for patient safety. On the other hand, the study set out to extend the category of vital documents and identify non-treatment related documents which, although not vital, contribute greatly to effective communication between doctors and foreign pa- tients and improve the quality of healthcare services. As such, the translation of these documents was also recommended by some respondents. This research met both ob- jectives, as shown in Figures 8 and 9. The results showed that a very high proportion of health professionals consider three types of documents to be vital for patient safety: consent forms, discharge papers and their discharge summaries, and patient information sheets. These documents were considered vital by over 60% of the respondents. In addition to these documents, imaging, laboratory and histopathology results, outpatient clinical notes, information on postoperative care and house rules were also considered vital by between 2% and 38% of health professionals. The most important non-treatment related documents 21Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 that were not considered vital but still in need of translation were wayfinding signs, the hospital and department map, the hospital’s webpage, and the hospital’s and/or department’s house rules. 6. Conclusion Identifying vital documents is the initial step in creating a systematic language assis- tance programme that provides written information for patients who do not speak the local language. This approach can greatly help to better meet the needs of hospi- tals’ diverse patient population and to prevent or minimize the occurrence of adverse events arising from language barriers in multicultural healthcare settings. In Hun- gary, however, it is unclear which language(s) these documents should be translated into because hospitals do not keep records of patients’ nationality or preferred lan- guage for discussing health issues. While patients’ place of birth may be considered, this data does not necessarily determine their mother tongue or other languages in which they can communicate. One possible solution could be to implement a sys- tem where hospitals collect information on patients’ language preferences during registration or admission (Regenstein et al. 2013). This could be done through a standardized questionnaire or checklist that is completed by the patient or a family member. Another solution could be to conduct a new survey to map the language preferences of potential patients (their mother tongues or a mediating language such as a lingua franca). To ensure the effectiveness of language assistance, it is crucial that the vital docu- ments on the list receive high-quality translations. One way to achieve this is by using translation guides (House 1997; Nord 1997; HHS 2003; Hablamos Juntos 2012). If a decision is made to translate these documents into a lingua franca like English instead of the patient’s mother tongue due to resource constraints, it is important to note that only a small percentage of foreign patients in Hungarian hospitals are native English speakers, while others may have varying levels of proficiency. This is reflected in the data shown in Figure 1 and 2. To ensure effective communication, readability tests should be included in the preparation of the translation guide. To enhance language assistance in the Hungarian healthcare sector, a research group was established in autumn 2021 by the Department of Languages for Specific Pur- poses of Semmelweis University and the Medical Communication and Translation Studies from the University of Szeged. The research group intends to collaborate with health professionals, medical lawyers and potential patients to create the full list of vital documents. The group will subsequently work on generating translation guides, 22 Ágnes Horváth: Translations for patient safety communication glossaries and sample texts for the identified documents, which may serve as train- ing resources for health care and medical translators and also be made accessible to healthcare institutions. The present research could thus serve as the basis for a large-scale translation project to improve patient safety in Hungarian hospitals when it comes to communicating with foreign patients. On the one hand, translations would promote effective com- munication between provider and patient, ensure patients’ rights to information, and reduce the number of adverse events resulting from language barriers. The language of the translations should be determined by the institution based on both the na- tionality of the patients who most frequently come to the clinic and their preferred language for discussing health issues. And finally, it is recommended that the literacy and functional health literacy level of foreign patients should be taken into account when preparing translations. 7. Limitations This research could be further extended beyond health professionals’ perspectives by asking patients which documents they consider the most important in health care and want to receive in a language they understand. Their answers could significantly refine the results obtained here. Although the integration of a legal perspective was crucial, the list of vital documents could still be improved if several medical lawyers’ viewpoints were incorporated. Moreover, it is worrying that the list of vital documents in Figure 8 does not encom- pass those that would facilitate communication between pharmacists and patients, where vital information on health is also provided. Additionally, it would be worthwhile to conduct a specific assessment of the needs of individuals with refugee status among the foreign patient population. There is a strong probability that they may have different preferences in terms of the type of documents required and their preferred language for health care, compared to the respondents in this research. References Agency for Healthcare Research and Quality, AHRQ. 2010. AHRQ Health Literacy Uni- versal Precautions Toolkit. Office of Minority Health, U.S. Department of Health and Human Services. https://www.ahrq.gov/health-literacy/improve/precautions/index. html. 23Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 Baruch, Erica, and Sherry. F. Walker. 2013. Health Equity and Language Access. How Lan- guage Access Issues Affect Patients, Policymakers and Health Care Providers. The Col- orado Trust. https://www.coloradotrust.org/sites/default/files/CT_LanguageAccess- Brief_final-1.pdf. 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Promoting Appropriate Use of Physicians’ Non-English Language Skills in Clinical Care: Recommendations for Policymakers, Organizations and Clinicians. American Medical Association. https:// 25Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27 www.immigrationresearch.org/system/files/Promoting_Appropriate_Use_of_Physi- cians_Non-English_Language_Skills_in_Clinical_Care.pdf. The Guide. n.d. Think Cultural Health. https://hclsig.thinkculturalhealth.hhs.gov/. The Joint Commission. 2010. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The Joint Commis- sion. www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf. Wu, Shinyi, M. Susan Ridgely, José J. Escarce, and Leo Morales. S. 2007. “Language Ac- cess Services for Latinos with Limited English Proficiency: Lessons Learned from Hablamos Juntos.” Journal of General Internal Medicine 22 (Suppl 2): 350–55. https:// doi.org/10.1007/s11606-007-0323-0. About the author Ágnes Horváth is an Assistant Lecturer at Semmelweis University, a medical univer- sity in Hungary. Her main research topic is patient safety communication for people who do not speak the local language. She has published on the legal framework for language assistance in different countries and the measures that have been introduced to prevent adverse events caused by language barriers. Her other major research topic is the identification of vital documents related to patient rights and patient safety in the Hungarian healthcare system, such as informed consent forms, and making them available in a foreign language for non-Hungarian patients. 26 Ágnes Horváth: Translations for patient safety communication APPENDIX Questionnaire on vital documents – Provider’s perspective (English translation of the Hungarian questionnaire) The questionnaire aims to identify which documents are vital, i.e., which are key to the success of the treatment and the patient’s recovery; and as a result, which docu- ments should be translated for the benefit of foreign patients. The questionnaire also aims to identify general information and guidance documents whose translation into a foreign language would be of additional help to foreign patients. The questionnaire is voluntary and anonymous. Your answers will be treated confidentially and used for scientific purposes only. Vital documents in Hungarian health care What department do you work in? 1. In your opinion, which documents (e.g., final reports, results, patient information sheets, consent forms) play a key role in the SUCCESS OF THE TREATMENT and the PATIENT’S HEALTH, and should therefore be translated into a foreign language for foreign patients? 2. In your opinion, which documents (e.g., final reports, results, patient information sheets, consent forms) are key from a PATIENTS’ RIGHTS point of view and should therefore be translated into a foreign language for foreign patients? There may be an overlap in your answer to the previous question. 3. In your opinion, which non-treatment related GENERAL INFORMATION and GUIDING DOCUMENTS (e.g., house rules, website, wayfinding signs, clinic map, parking information) should be translated into a foreign language for foreign patients? 27Stridon. Journal of Studies in Translation and Interpreting, Volume 3 Issue 1, pp. 5–27