SBAR Nursing Shift Handover: A Structure That Reduces Errors

Why is the handover between shifts a risky moment?

At every handover, responsibility for a patient’s care passes from one person to another, along with a great deal of information: changes in condition, pending test results, delayed medications and concerns nobody wrote in the chart. Any detail lost here can become a treatment delay or a medication error.

That is why the World Health Organization included improving information exchange when patients transfer between care providers among the “nine patient safety solutions” it launched in 2007. ^[3] The Joint Commission defines a handoff as the transfer of responsibility for a patient’s care achieved through effective communication, whether within one facility or between facilities, and has issued a formal alert on the hazards of inadequate hand-off communication. ^[2]

What is SBAR?

SBAR is a structured communication framework that the Institute for Healthcare Improvement (IHI) describes as an easy-to-remember, concrete mechanism, especially useful for urgent conversations that need a clinician’s immediate attention. It was developed by Michael Leonard, Doug Bonacum and Suzanne Graham at Kaiser Permanente of Colorado and has since spread to many health systems. ^[1]

Its four elements are: ^[1]

• Situation: a brief statement of the problem.
• Background: short, relevant information about the situation.
• Assessment: your analysis of the problem and the options being considered.
• Recommendation: the action requested or proposed.

Why does a standard framework work?

The core idea is that both sides know in advance what will be said and in what order. ^[1] When every nurse improvises, one starts with a long medical history and leaves the current problem to the end, while another just says “all fine”. A standard framework means the receiver expects specific elements and notices at once if one is missing.

The assessment element in particular helps nurses say plainly what worries them. Many nurses report the numbers without saying “I think this patient is deteriorating”, so the physician or receiving colleague misses the most important conclusion.

How do you build a structured shift handover in your unit?

The Joint Commission recommends standardised, evidence-based communication tools, training staff in handoffs, leaders making handoffs a priority within a culture of safety, and monitoring and improving handoff quality continuously. ^[2] In practice that means:

1. One standard paper or electronic template based on SBAR, completed by the giver before the shift ends.
2. Prioritise: start with unstable and newly admitted patients, then the rest.
3. A time and place with as few interruptions as possible: handing over amid phones and requests increases the chance of forgetting.
4. Bedside handover where possible: to check lines, infusions and the patient’s condition, while respecting privacy.
5. Receiver summary: the receiver repeats the key points and asks about anything unclear; the handover does not end when the giver stops talking.

Common mistakes that weaken handover

• Relying on memory without a written template.
• Giving every detail equal weight, so critical information is lost among routine items.
• Leaving out pending tasks: a test result still awaited, or a medication due in an hour.
• No clear recommendation, so the handover ends without the receiver knowing what to do first.
• Treating SBAR as a form to fill in rather than a conversation; the template supports the dialogue, it does not replace it.

A hypothetical example: handing over a post-operative patient

At the morning handover, the outgoing nurse says: “Bed 12, Mr Ahmed, 64, has had increasing abdominal pain for the past hour (situation). He had colon surgery yesterday and is on prophylactic anticoagulation (background). His blood pressure has dropped from 130 to 105 and his pulse is up to 108; I’m worried about bleeding (assessment). I informed the on-call physician ten minutes ago, and I suggest observations every 15 minutes until they arrive, and making sure the requested blood test is ready (recommendation).”

The incoming nurse summarises: “Observations every quarter hour, check the blood test, and call the physician if the pressure drops further.” They then check the wound site and infusions together at the bedside. The case is hypothetical, to illustrate the method.

Conclusion

Good handover is not only an individual skill but a unit system: a standard structure such as SBAR, a suitable time and place, a receiver who summarises and asks, and leaders who monitor quality. With these in place, responsibility passes on with the full picture.