Articles: Medical Errors
SBAR
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What causes medical errors? The Joint Commission, which
accredits the majority of hospitals in this country and
some nursing homes and other facilities, analyzes the root
causes of sentinel or critical events. Miscommunication
is the most common cause of patient injury or death. SBAR
(Pronounced S-Bar) is a formalized method of communicating
with other healthcare practitioners that is sweeping the
country. Its use is spreading within hospitals, and may
soon become so commonplace that it will be recognized as
close to, if not a standard of care.
SBAR
was developed by Kaiser Permanente of Colorado, and has
been increasingly adopted by hospitals through the United
States. SBAR is used to report to a healthcare provider
a situation that requires immediate action, to define the
elements of a hand off of a patient from one caregiver to
another, such as during transfers from one unit to another
or during shift report, and in quality improvement reports.
Liability issues may surround the communication that occurred
in any clinical situation, but particularly when unexpected
changes in a patient’s condition occur. It is often
difficult to determine what the healthcare prescriber (physician,
physician assistant, nurse practitioner) was told. An inexperienced
or fatigued nurse may omit specific important information.
One of the goals of SBAR is to provide a structure for such
communication. The elements of SBAR are explained below
and applied to contacting a prescriber.
Situation:
When calling a healthcare provider to report a change in
the patient’s condition, the nurse identifies his
or her name and unit, the name and room number of the patient,
and the problem. The nurse describes what is happening at
the present time that has warranted the SBAR communication.
Situation:
“Dr. Little, this is Maria Sanchez of 3 North. I am
calling you to notify you that your patient, Liam Kelly,
in Room 319-2, fell on the floor today while being transferred
out of bed.”
Background:
The nurse includes relevant background information specific
to the situation. For example, this could include the patient’s
diagnosis, his mental status, current vital signs, complaints,
pain level, and physical assessment findings.
Background:
“As you know, Mr. Kelly had a discectomy and bone
fusion on January 17. His legs have been weak since surgery.
He fell when our aide was helping him get up with a walker.
His current vital signs are 145/90, pulse of 88 and respirations
of 20. He is able to move all of his extremities, although
he is complaining of pain in his incisional site of 7 on
a scale from 1-10.”
Assessment:
This step of the communication provides the nurse with the
opportunity to offer an analysis of the problem. If the
situation is unclear, the nurse tries to isolate the problem
to the body system that might be involved and describes
the seriousness of the problem. This may be challenging
for some nurses because many have been conditioned to hold
back the results of their critical thinking skills. Some
facilities use the assessment step to convey more extensive
data about the patient, such as changes from prior assessments.
Assessment:
“I see no changes in his neurological status since
he fell; neither of his legs is shortened and externally
rotated. He is quite anxious now and also worried something
his neck has been injured.”
Recommendation:
The nurse states what he or she thinks would help resolve
the situation or what is the desired response. This might
be phrased in the form of a question: “Do you think
we should give him a medication, perform lab work, do an
xray, perform cardiac monitoring, or transfer to another
unit? Will you come to evaluate him?”
Recommendation:
“I believe it would reassure Mr. Kelly if you would
examine him. When can we expect you to come?”
Tips
for attorneys
1. Note any mention of SBAR communication in the medical
record.
2. In a nursing or medical negligence claim, inquire if
the facility has adopted the use of SBAR. If so, ask to
see the materials used to educate the staff, and for any
policies or procedures that may exist relating to SBAR communication.
3. For more information, see www.ihi.org,
and search for “SBAR”.
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