SBAR checklist can cut risk at patient handoff

Patient handoff now is known to be a high-risk time, with the transfer of responsibilities opening up the potential for misunderstandings, incomplete information, and other failures of communication that can threaten patient safety. Some risk managers and clinicians are embracing a new strategy that they say can significantly reduce the risk.

The new method is known as the SBAR checklist. SBAR stands for the key elements to be communicated in the patient handoff process: situation, background, assessment, and recommendation. Co-creator Douglas Bonacum, MBA, vice president of safety management with Kaiser Permanente in Oakland, CA, says the SBAR method provides clinicians a framework for communicating effectively about a patient's condition and needs.

"SBAR is an easy-to-remember mechanism that people can find useful for any conversation really, but especially this critical moment at patient handoff," he says. "It focuses on the critical elements that are needed to make this handoff effective and to reduce the chance that important information will be overlooked or misunderstood."

Bonacum created the checklist along with Suzanne Graham, PhD, RN, director of patient safety for Kaiser Permanente, and Michael Leonard, MD, physician leader for patient safety. Bonacum notes that the SBAR method was inspired by the 1999 Institute of Medicine report on medical errors and patient safety, which pointed out that patient handoff can be particularly risky. Improving communication at patient handoff is part of the 2007 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals.

The SBAR checklist helps overcome a key cause of errors at patient handoff: the big difference in how doctors and nurses communicate, Bonacum explains. Whereas nurses tend to frame their comments in relation to a nursing plan, physicians are more interested in whatever might be a problem at the moment and what they need to do to fix it.

The structured method of communication helps overcome those innate differences, Bonacum says. The SBAR checklist is used throughout the Kaiser Permanente system and is spreading quickly to other providers.

SBAR gives formal structure

One of the systems adopting the SBAR checklist is OSF Healthcare in Peoria, IL, which operates hospitals and medical groups in Illinois and Michigan. John Whittington, MD, patient safety officer and director of knowledge management at OSF, says his organization has phased in SBAR since 2002. OSF leaders were looking for a solution after recognizing that physicians and nurses often did not communicate well.

"Before that, there was no common mental model of how we would share information between disciplines or within disciplines," he says. "There was no formal structure for communicating, so it was left up to people to do it in whatever they thought worked. It was typical communication between people, which means sometimes it was effective and sometimes information was lost in the process."

Physicians and staff were introduced to the SBAR method and encouraged to use it in many scenarios. Whittington notes that the checklist can be used for much more than just actual patient handoffs. The topics in SBAR can be useful in many circumstances in which clear communication is important, he explains, and staff were urged to think in SBAR terms when conveying any information to a physician or colleague. At actual handoffs, such as at a shift change, staff members were encouraged to use the SBAR checklist in more detail.

Not needed for every discussion

In 2002, OSF also was introducing the concept of "crew resource management," which encourages clear and communication among team members, so SBAR fit well as a tool to use. To train staff and physicians on SBAR, OSF used several methods. SBAR education was incorporated into team resource management training and general orientation. Practical help included SBAR pocket cards for clinicians and laminated SBAR "cheat sheets" posted at each phone. One of the best examples of when SBAR can be useful is when a nurse is calling a physician at home.

Education sessions also included role-playing scenarios in which clinicians were given a hypothetical patient situation and encouraged to use SBAR in discussing it.

Whittington notes that staff adapted quickly to the use of SBAR, although there was some hesitancy in providing the "recommendation" to physicians. Physicians were encouraged to listen for the SBAR components and encourage staff to share their recommendation if it was not initially provided.

OSF leaders also found that they needed to acknowledge when SBAR is unnecessary. Some brief, straightforward communication does not require SBAR, he says. If a physician has requested that a nurse call when a specific lab result comes in, for example, it's not necessary to go through the entire SBAR list for that conversation when she calls an hour later, Whittington says.

"Physicians and staff need to know that you're not expecting them to run down unnecessary information every time they have a conversation," he says.

Sources

For more information, contact:

  • Douglas Bonacum, Vice President of Patient Safety, Kaiser Permanente. E-mail: doug.bonacum@kp.org.
  • John Whittington, MD, Patient Safety Officer and Director of Knowledge Management, OSF Healthcare, 800 N.E. Glen Oak Ave., Peoria, IL 61603-3200. Telephone: (309) 655-4846. E-mail: john.w.whittington@osfhealthcare.org.