Authors: Haig, Kathleen M.; Sutton, Staci; Whittington, John

Source: Joint Commission Journal on Quality and Patient Safety, Volume 32, Number 3, March 2006 , pp. 167-175(9)

Publisher: Joint Commission Resources

Abstract:

Background: The 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 Study: An 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 Taken: The 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.

Discussion: Staff 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.

Document Type: Research article

Publication date: 2006-03-01

More about this publication?

• Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
  
  Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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