• Kathleen M Haig, Staci Sutton, and John Whittington.
• OSF St Joseph Medical Center, Bloomington, Illinois, USA.
• Jt Comm J Qual Patient Saf. 2006 Mar 1;32(3):167-75.

BackgroundThe importance of sharing a common mental model in communication prompted efforts to spread the use of the SBAR (Situation, Background, Assessment, and Recommendation) tool at OSF St. Joseph Medical Center, Bloomington, Illinois.Case StudyAn elderly patient was on warfarin sodium (Coumadin) 2.5 mg daily. The nurse received a call from the lab regarding an elevated international normalized ratio (INR) but did not write down the results (she was providing care to another patient). On the basis of the previous lab cumulative summary, the physician increased the warfarin dose for the patient; a dangerously high INR resulted.Actions TakenThe medical center initiated a collaborative to implement the use of the SBAR communication tool. Education was incorporated into team resource management training and general orientation. Tools included SBAR pocket cards for clinicians and laminated SBAR "cheat sheets" posted at each phone. SBAR became the communication methodology from leadership to the microsystem in all forms of reporting.DiscussionStaff adapted quickly to the use of SBAR, although hesitancy was noted in providing the "recommendation" to physicians. Medical staff were encouraged to listen for the SBAR components and encourage staff to share their recommendation if not initially provided.

This article appears in the collection: SBAR and anaesthetic handover communication.

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