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Poor communication is one of the most common causes for dissatisfaction with health services. Research evidence shows the strong links between team communication and clinical outcomes.

Communication issues can happen anywhere in the health care system. Transitions between care settings are particularly vulnerable. 

One tactic is to reduce communication breakdowns by making them more visible. People can then address omissions or misunderstandings before any harm comes to the patient. Before you adopt a communication intervention,  ask yourself if it: 

  • is easy to understand and follow? 
  • is consistent and predictable? 
  • is resilient? If the process fails in one part of the system can another part can recover the error? 
  • steers users to do the right thing in the right way?   Does it reduce "work arounds" and reliance on memory? (2).

Tools and interventions: SBAR

Situation-Background-Assessment-Recommendation (SBAR) is a communication tool designed to support staff sharing clear, concise and focused information. 

  • Situation.  Identify yourself and site you are calling from. Identify the patient by name and the reason for your report. Describe your concern.
  • Background. Give the patient's reason for admission. Explain significant medical history. You then inform the other person of the patient's background. Include admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results.
  • Assessment. Vital signs; Contraction pattern; Clinical impressions, concerns.
  • Recommendation. Explain what you need. Be specific about request and time frame; Make suggestions; Clarify expectations

The SBAR tool is used in a range of different settings. It  is used by many different staff members, clinical and non-clinical. The SBAR prompts are printed on notepads, pocket cards and stickers to remind staff to use the standard method of communication.


1. Rabol et al (2011) Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety March; 20(3): pp268-74. doi: 10.1136/bmjqs.2010.040238.

2. Nadzam D (2009) Nurses’ role in communication and patient safety. Journal of Nursing Care Quality, Jul-Sep;24(3): pp.184-8.

Page last updated - 12/02/2023