Miscommunication or omission of critical patient information contributes to preventable medical errors that result in 98,000 patient deaths each year. Hand-off communication process are noted as major contributors to patient safety. Improved patient care outcomes have been demonstrated by implementation of a standardized hand-off communication tool. Standardized tools that are valid and reliable are available for use, but are only effective when consistently implemented. The Situation Background Assessment Recommendation (SBAR) communication tool is designed to improve the communication between nurses and other health care providers. Internal audits have demonstrated that some of the delay in treatment and unnecessary hospitalization was due to inappropriate communication in the nursing home. This proposed change project, once sustained, will improve patient outcome and decrease healthcare expenses.
