SBAR
Situation
Background
Assessment
Recommendation
Purpose of SBAR 414
Patient handoffs in perioperative care are often inconsistent, leading to delays, missing information, and potential safety risks. At our local Milwaukee facility, we’ve identified a gap in communication during the critical transitions between day surgery and operating room teams.
[S] Situation
Communication errors contribute to up to 80% of serious medical mistakes. Despite dedicated staff, unstructured handoff processes have resulted in confusion and inefficiencies. Currently, handoffs vary by provider and shift, which introduces risk. Nurses have expressed frustration and a desire for a simple, standardized approach. SBAR (Situation, Background, Assessment, Recommendation) is a nationally recognized communication tool proven to improve clarity and patient outcomes.
[B] Background
[A] Assessment
[R] Recommendation
Adopt SBAR414 as the standard for all handoffs between day surgery and the OR. Use the tool consistently, document exceptions clearly, and follow the pre-procedure checklist (including DVT prophylaxis and blood products). Together, we can build a culture of safety that doesn't take a day off—one handoff at a time.
A locally adapted SBAR tool—SBAR414—will be implemented starting May 6, 2025, across perioperative units. The tool includes a physical form that begins in pre-op and is completed through to the OR, focusing documentation on key elements while flagging exceptions. The form is also being refined to reduce redundancy and improve visual cues, especially in the assessment section.
About
the Project
SBAR414 is a quality improvement initiative focused on improving perioperative handoff communication using the SBAR (Situation, Background, Assessment, Recommendation) tool.
This project promotes consistency, safety, and efficiency in patient transitions between day surgery and operating room teams.
Connect with the Project Lead
Whether you're looking for support, resources, or just want to learn more about how SBAR can make handoffs safer and more effective—I'm here to help!
Kate Wolf, MSN, RN, CNOR DNP Student
kwolf@chamberlain.edu
262-565-8595