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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 handoff 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 health care 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 x-ray, 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, and search for “SBAR”

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Filed In: Medical Errors