Patient safety is the most important thing in any hospital. Everyday, every hospital staff do their best to ensure no harm to any patient in the hospital. The root cause of every patient safety incident is primarily due to poor, ineffective or lack of communication. This is communication between the hospital staff as well as between hospital staff and their patients. How do you effectively address the communication problem? The healthcare industry has learned from the aviation industry. Taking a flight has been safer than being in the operating theater or ICU of a hospital. The airline industry, following major crashes, have managed to make air travel the safest thing to do. Key safety-related domains that emerged in the airline industry and adapted by healthcare included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. SBAR is one of the practices adapted from the airline industryas well. Introduction to SBAR for effective communication in hospital. Ineffective communication is the root cause of all errors, adverse incidences in hospital. Structured communication between personnel helps reduce this root cause.

1. Flight Plan To Patient Safety
CRM
Crew Resource Management
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KTSH HOD Meeting

2. If humans are involved, error is inevitable.
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1. The Captain began the takeoff roll without clearance from the control
tower (rushed procedure).
2. Neither the co-pilot (CP) nor the flight engineer (FE) were certain
whether a takeoff clearance had been received. (loss of situational
awareness)
3. The CP and the FE strongly suspected that another airplane was on the
runway hidden in the fog. (loss of situational awareness)
4. The CP and the FE dropped weak hints to the Captain seemingly for fear
of offending the Captain. (failed teamwork)
5. The Captain brusquely dismissed both hints and shoved the throttles
forward and accelerated the B747 towards the world’s worst aviation
disaster. (communication failure)

3. Aviation and Healthcare Have Similarities
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1. Extremely complex.
2. Require highly trained professionals.
3. Function under stress.
4. Entrusted with the safety of others.
5. Human factors cause the majority of errors.

4. Same human factors that cause errors
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1. Fatigue
2. Stress.
3. Poor communication and teamwork.
4. Preventable error chain.
5. Cultures of blame.

5. Safety Tools in Aviation
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• Checklists
• Briefings
• Debriefings
• Flight standing orders
• Standard Operating Procedures
• Standard communications

6. Communications skills deficiency
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Not
technical competency
Under conditions of overload, stress and fatigue,
we will necessarily make errors.

7. Communication
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• Verbal – face-to-face (1 to 1)
• Referral / handover / briefing
• Verbal – face-to-face (1 to group)
• Handover/ briefing
• Verbal – phone, video (live)
• Referral / handover/ briefing/ question / advice /
report
• Verbal – phone (recorded message,
voice mail)
• Referral / question / advice / report
• Written – email, WhatsApp
• Referral/ question / advice
• Written - letter
• Referral/ question / advice
• Written – report
• Update / interim report / final report
• Written – telephone message
• Emergency / urgent / non-urgent

8. Communication and Patient Safety
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• Significant proportion of patient safety incidents are the
result of communication failures:
• between healthcare professionals - clinical and non-
clinical
• between healthcare staff and patients
• Communication failure results from;
• poor structure of message
• lack of planning
• lack of key information
• poor prioritisation
• desired result not achieved
JCAHO – communication failure is the leading cause of inadvertent patient harm (2004)

9. Examples
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• Nurse asks doctor to take blood from patient, bed 3 bay 1.
• Later nurse asks all patients in bay 1 if they have had their pre-op
bloods taken.
• Patient in bed 3 says he has had bloods done twice.
• Manager talks to colleague about a project which has not
been completed on time.
• Colleague apologises and says he has had a ‘virus’ attack.
• Manager assumes viral illness, colleague means a computer virus.
• What examples can you think of?

10. Communication in healthcare
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Handover
Continuity of care
Briefing
Sharing mental
models
Call for
help
Escalation of
concerns
• Roles and
responsibilities
• Chain of
command
• Assertiveness
• Preparing to act
• Sharing a plan
• Co-ordination of
effort
• Data
information and
insight
• Acceptance of
responsibility
• Point of transfer

11. Attention Loop
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Decreasing
Attention
Time
Transmission
Evaluating
Reflecting
Listening
Formulating
Response
Listening
Challenging or Unwelcome News

12. Organizing thoughts
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• Prepare
• Why are you having the conversation ?
• What is the message?
• Ensure the receiver is ready
• How will you know if you have the right result?
• Precise
• Select the key issue (s)
• Provide sufficient additional information to provide context but remove
extraneous detail
• Use short sentences
• Avoid jargon
• Prioritise
• Put the key points first
• Clarify anything which might be ambiguous

13. Delivery
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• Who are you?
• Where are you ?
• Who are you talking to ?
• Big Hits
• Critical Information
• Big Picture
• Context and boundaries
• Relevant Detail
• Keep it short

14. What we need for effective communication
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• Mechanism (established processes): to frame
conversations
• Tool (distinct design) to share concise and
focused information.
• Standard of Communication
• Indicator of Effective Communication

15. SBAR for common scenarios ineffective communication
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• Many exchanges are not face-to-face so only the spoken / written
word is available.
• The person being called will respond only to what you say and they
may have limited time or capacity to deal with your concerns
• There may be no support from shared documents or images so the
language which you use must be clear and unambiguous.
• There may not be an established personal relationship between the
person calling for help and the person being called upon.
• The person taking the call may not be in a position to listen carefully,
take notes or give you their undivided attention when they first
answer.

16. What is SBAR?
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• SBAR is a structured method for communicating critical information
that requires immediate attention and action
• SBAR improves communication, effective escalation and increased
safety
• It clarifies WHAT and HOW information should be communicated.
• SBAR has well-structured 4 steps
– Situation
– Background
– Assessment
– Recommendation

17. What is SBAR?
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Situation
What is happening now ?
Background
What has happened in the past that is relevant ?
Assessment
What is the problem / issue in your view ?
Recommendation
What do you think needs to happen now ?
What does the receiver want you to do ?

18. SBAR Template – Nurse-to-Physician
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Situation: What is the situation you are calling about?
• Identify self, unit, patient, room number.
• Briefly state the problem, what is it, when it happened or started, and how severe.
Background: Pertinent background info related to the situation
could include:
• The admitting diagnosis and date of diagnosis.
• The list of current medications, allergies, IV fluids and labs.
• Most recent vital signs.
• Lab results – provide the date and time the test was done and the results of
previous tests for comparison.
• Other clinical info.
• Code status.
Assessment: What is the nurse’s assessment of the situation?
Recommendation: What is the nurse’s recommendation or what does he/she want?
• Notification that the patient has been admitted.
• Patient needs to be seen now.
• Order change.

19. Why use SBAR?
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• To reduce the barrier to effective communication across different
disciplines and levels of staff.
• SBAR creates a shared mental model around all patient handoffs
and situations requiring escalation, or critical exchange of
information (handovers)
• SBAR is memory prompt; easy to remember and encourages prior
preparation for communication
• SBAR reduces the incidence of missed communications

20. Situation
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• Identify yourself the site/unit you are calling from
• Identify the patient by name and the reason for your report
• Describe your concern
• Firstly, describe the specific situation about which you are calling, including
the patient's name, consultant, patient location, resuscitation status, and vital
signs.
For example:
"This is Asfayanti, SRN on Mahaganu Ward. The reason I'm calling is
that Cik Rozita in room 444 has become suddenly short of breath, her
oxygen saturation has dropped to 88 per cent on room air, her
respiration rate is 24 per minute, her heart rate is 110 and her blood
pressure is 85/50.”

21. Background
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• Give the patient's reason for admission
• Explain significant medical history
• Overview of the patient's background: admitting diagnosis, date of admission,
prior procedures, current medications, allergies, pertinent laboratory results and other
relevant diagnostic results. For this, you need to have collected information from the
patient's chart, flow sheets and progress notes.
For example:
“Cik Rozita is a 69-year-old woman who was
admitted from home three days ago with a community
acquired chest infection. She has been on intravenous
antibiotics and appeared, until now, to be doing well. She
is normally fit and well and independent.”

22. Assessment
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• Vital signs
• Clinical impressions, concerns
For example:
• You need to think critically when informing the doctor of your
assessment of the situation.
• This means that you have considered what might be the underlying
reason for your patient's condition.
• If you do not have an assessment, you may say:
“Cik Rozita’s vital signs have been stable from admission
but deteriorated suddenly. She is also complaining of
chest pain and there appears to be blood in her sputum.
She has not been receiving any venous thromboembolism
prophylaxis.”
“I’m not sure what the problem is, but I am worried.”

23. Recommendation
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• Explain what you need - be specific about request and timeframe
• Make suggestions
• Clarify expectations
• Finally, what is your recommendation?
• That is, what would you like to happen by the end of the conversation with the physician?
• Any order that is given on the phone needs to be repeated back to ensure accuracy.
"Would you like me get a stat CXR? and ABGs?
Start an IV? I would like you to come immediately”

24. SBAR for listening
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Sender Receiver
S Situation Set aside assumption
B Background Be attentive
A Assessment Ask questions
R Recommendation Reflect
R Rationale Respond

25. SBAR in EMR
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26. How can SBAR help me?
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• Self-confidence. Allows you to communicate forcefully and
effectively.
• Better work life. Closes the traditional hierarchy between staffs.
• Positive participation. Encourage assessment skill.
• Trust building. Staff anticipate the information needed by
colleagues.
• Points to action

27. SBAR at the Information Level
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• Reducing repetition.
• The right level of detail.
• The right sequence of flow.
• Concise and focused information.

28. SBAR at the Organizational Level
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• To foster a culture of patient safety.
• To develop effective communication and teamwork
• Easy to remember and can reduce the time spent on
patient handover.
• An ROP (Required Organizational Practice) requested
by MSQH.

29. Uses and settings for SBAR
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• Inpatient or outpatient
• Urgent or non urgent communications
• Conversations with a physician, either in person or over
the phone
• Particularly useful in nurse to doctor communications
• Also helpful in doctor to doctor consultation
• Discussions with allied health professionals
• e.g Respiratory therapy
• e.g Physiotherapy
• Conversations with peers
• e.g Change of shift report
• Escalating a concern
• Handover from an ambulance crew to hospital staff

30. Safety culture evolves
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31. Safety culture evolves
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32. Safety culture evolves
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33. Next step
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To err is human,
to forgive is
not company policy.
KTS Hospital HR Policy

34. References
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35. Human Factors: The Foundation of Reliability
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• Effective team performance
• Structured communication
• Reliable processes
• Continuous learning and improvement

36. Effective communication and teamwork requires:
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Structured Communication SBAR
Assertion/Critical Language Key words, the ability to speak up and stop the
show
Psychological Safety An environment of respect
Effective Leadership • Flat hierarchy,
• Sharing the plan,
• Continuously inviting other team members
into the conversation,
• Explicitly asking people to share questions or
concerns,
• Using people’s names

37. Assertion
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• Model to guide and improve assertion in the interest of
patient safety.
GET PERSON’S
ATTENTION
EXPRESS
CONCERN
STATE
PROBLEM
PROPOSE
ACTION
REACH
DECISION

38. Importance of Assertion/Critical Language
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• Because we know 25 - 40% of nurses tell us on the
Safety Attitude Questionnaire they would be hesitant
to speak up if they saw a doctor making a mistake.
• Often people do not speak up or do so quite indirectly.
• Knowing the plan — using SBAR — makes it much
easier to speak up.

39. Briefings
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• Share the game plan
• Set the stage — psychological safety
• Norms of conduct
• Disavow perfection – a little humility goes a long way
• Engage every participant using eye contact and people’s names
• Explicitly ask for input about concerns or issues
• Provide information and talk about next steps
• Seek useful information
• Update as needed — build into procedure

40. Debriefing
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• An opportunity for individual, team and organizational learning
• The more specific, the better
• What did we do well? What did we learn? What would we do
differently next time?
• Take a minute or two to learn while it is fresh in everyone’s head

41. Effective Debriefing
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• Be crisp and to the point
• Do it while the experience is fresh
• Everyone gets a chance to speak
• Start with the junior folks — otherwise they can be
overshadowed by the veterans
• Avoid judgment and criticism — this has to be a positive
learning experience

42. Standard communication tool
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43. Standard communication tool
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