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Impact of the communication and
patient hand-off tool SBAR on patient
safety: a systematic review
Martin Müller,1,2 Jonas Jürgens,2 Marcus Redaèlli,2 Karsten Klingberg,1
Wolf E Hautz,1 Stephanie Stock2

To cite: Müller M, Jürgens J, Abstract

Redaèlli M, et al. Impact Strengths and limitations of this study
Objectives  Communication breakdown is one of the main
of the communication causes of adverse events in clinical routine, particularly
and patient hand-off tool ►► This systematic review was conducted in accor-
in handover situations. The communication tool SBAR
SBAR on patient safety: a dance with the Cochrane Collaboration standards
(situation, background, assessment and recommendation)
systematic review. BMJ Open using a validated tool for quality assessment of the
2018;8:e022202. doi:10.1136/ was developed to increase handover quality and is widely
identified studies.
bmjopen-2018-022202 assumed to increase patient safety. The objective of this
►► Five well-known databases as well as the referenc-
review is to summarise the impact of the implementation
►► Prepublication history and es of the included studies were searched using an
of SBAR on patient safety.
additional material for this open search strategy.
Design  A systematic review of articles published on SBAR
paper are available online. To ►► Reliability of the study selection, data extraction and
was performed in PUBMED, EMBASE, CINAHL, Cochrane
view these files, please visit rating of the study quality was ensured using two
the journal online (http://​dx.​doi.​ Library and PsycINFO in January 2017. All original
independent reviewers.
org/​10.​1136/​bmjopen-​2018-​ research articles on SBAR fulfilling the following eligibility
►► Studies in which SBAR (situation, background, as-
022202). criteria were included: (1) SBAR was implemented into
sessment and recommendation) was part of a larger
clinical routine, (2) the investigation of SBAR was the
Received 17 February 2018
quality improvement initiative and outcomes that did
primary objective and (3) at least one patient outcome was
Revised 11 July 2018 not measure the incidence of adverse events were
reported.
Accepted 26 July 2018 not included in this review.
Setting  A wide range of settings within primary and
►► The heterogeneity of the studies impeded to test for
secondary care and nursing homes.
publication bias or to perform a meta-analysis.
Participants  A variety of heath professionals including
nurses and physicians.
Primary and secondary outcome measures Aspects
defined by the World Alliance for Patient
of patient safety (patient outcomes) defined as the
occurrence or incidence of adverse events. Safety of WHO as ‘the reduction of risk of
Results  Eight studies with a before–after design and unnecessary harm associated with healthcare
three controlled clinical trials performed in different clinical to an acceptable minimum’.2 To illustrate the
settings met the inclusion criteria. The objectives of the impact of patient safety on healthcare quality,
studies were to improve team communication, patient the incidence of adverse events is commonly
hand-offs and communication in telephone calls from cited. Following the definition of Brennan et
nurses to physicians. The studies were heterogeneous al,3 adverse events are injuries that are caused
with regard to study characteristics, especially patient by medical conduct resulting in prolonged
outcomes. In total, 26 different patient outcomes were hospitalisation and/or disability at the time
© Author(s) (or their measured, of which eight were reported to be significantly
of discharge. The Joint Commission reported
employer(s)) 2018. Re-use improved. Eleven were described as improved but no
that poor communication is a contributing
permitted under CC BY-NC. No further statistical tests were reported, and six outcomes
commercial re-use. See rights did not change significantly. Only one study reported a factor in more than 60% of all hospital
and permissions. Published by descriptive reduction in patient outcomes. adverse events they reviewed.4 Poor commu-
BMJ. Conclusions  This review found moderate evidence for nication is found in many different health-
1
Department of Emergency improved patient safety through SBAR implementation, care settings and is especially prominent in
Medicine, Inselspital, Bern especially when used to structure communication over the patient hand-offs and settings where fast and
University Hospital, University of
phone. However, there is a lack of high-quality research on effective management is indispensable. Such
Bern, Bern, Switzerland
2
Institute of Health Economics
this widely used communication tool. settings include the perioperative period,5 the
and Clinical Epidemiology, Trial registration none intensive care unit (ICU)6 and the emergency
University Hospital of Cologne, department.7 The components and processes
Cologne, Germany of communications are complex and prone
Correspondence to Introduction  to misunderstanding.8 To overcome these
Dr Martin Müller; Patient safety is crucial for the delivery of barriers, communication strategies are desir-
​martin.​mueller2@​insel.​ch effective, high-quality healthcare1 and is able, which take little time and effort to

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Table 1  SBAR communication technique, adapted table 16 18 63 64
Questions Description Example
S Situation What is going on First, the speaker presents the situation, by ‘Dr Preston, I’m calling
with the patient? identifying himself, stating the patient’s name and about Mr Lakewood, who’s
What is the situation briefly describing the problem having trouble breathing’
you are calling/
communicate
about?
B Background What is the The speaker then provides the background, such ‘He’s a 54 year old man
background or as the patient’s diagnosis or reason for admission, with chronic lung disease
context on this medical status and relevant history. The patient’s who has been sliding
patient? chart is reviewed and questions the other care downhill, and now he’s
provider may have are anticipated acutely worse’
A Assessment What is the Then specific information on vital signs, recent ‘I don’t hear any breath
problem? laboratories and other quantitative or qualitative sounds in his right
data related to the patient’s current state are chest. I think he has a
provided. This section can include a provisional pneumothorax’
diagnosis or clinical impression
R Recommendation What is the An informed suggestion for the continued care ‘I need you to see him right
next step in the of the patient has to be made by the speaker. now. I think he needs a
management of the The immediate need is explained clearly and chest tube’
patient? specifically, including what is necessary to address
the problem
The tool is available for download from the website of the Institute for Healthcare Improvement.9

complete, deliver comprehensive information efficiently, However, the actual effect of SBAR on patient outcome
encourage interprofessional collaboration and limit is unclear. The wide adoption of SBAR (or any other
the probability of error.9–11 The SBAR (situation, back- communication strategy) without proven benefit may
ground, assessment, recommendation) instrument (see paradoxically limit improvements because a problem
table 1) and its derivatives ISBAR, SBAR-R, ISBARR and presumably solved will be less addressed. Thus, the
ISOBAR fulfil this need and are widely used in different purpose of this systematic review is to summarise the avail-
healthcare facilities as a communication and hand-off able evidence for and evaluate the impact of the imple-
tool both intraprofessionally and interprofessionaly.12–15 mentation of SBAR in clinical settings on patient safety as
By virtue of a clear structure, SBAR calls for the provi- measured by the incidence of adverse events.
sion of all relevant information, organised in a logical
fashion.16 Furthermore, it enables a preparation before
the communication process,16 17 and because sender and Methods
receiver share the same mental model, understanding Search strategy
and awareness are expected to be higher.18 Besides, it A systematic search for articles published on SBAR was
reduces inhibitions especially in hierarchical context by performed in PUBMED, EMBASE, CINAHL, Cochrane
encouraging the sender to provide a personal assessment Library and PsycINFO via OvidSP. The search was
and suggestion of the situation (‘Recommendation’).19 conducted in January 2017. It was augmented by a review
The SBAR tool is regarded as a communication technique of the references of all articles included. Search terms used
that increases patient safety and is current ‘best practice’ in all electronic medical databases were SBAR, ISBAR,
to deliver information in critical situations.16 20 SBAR-R, ISBARR and ISOBAR (combined as text words
A number of studies have investigated ‘soft’ outcomes with the Boolean operator ‘OR’). The detailed search
such as employee satisfaction21 22 and interdisciplinary strategy is provided in online supplementary appendix A.
communication19 23 in relation to SBAR. Positive reso- No restrictions were applied in terms of time, language or
nances of employees after the introduction of SBAR type of article. No review protocol exists.
were reported24–28 with improvements of the communi-
cation perception and interdisciplinary teamwork29–33 as Eligibility criteria
well as the quality of the communication.34–40 Especially All original research articles on SBAR fulfilling the
in patient hand-off, the quality of the communication following eligibility criteria were included:
and the completeness of transferred information was ►► SBAR was implemented into clinical routine,
increased after the implementation of SBAR.41–44 Further- ►► The investigation of SBAR was the primary objective
more, less time was needed for the patient hand-off in of the study (as opposed to, for example, SBAR as part
several studies.40 42 45 of a larger quality improvement initiative),

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►► At least one patient outcome was reported (eg, Data synthesis
mortality or secondary ICU admission). In accordance The intraclass correlation coefficient (ICC) using Stata’s
with the definition of WHO,2 aspects of patient safety ICC command with a two-way mixed-effects model was
(patient outcomes) were defined through outcome calculated to quantify the rater agreement on study inclu-
parameters measuring the occurrence or incidence of sion as well as on quality ratings of the studies included.
adverse events. The heterogeneity of reported study designs, outcome
Exclusion criteria were: measures, settings and forms of SBAR interventions
►► Articles that only describe the SBAR tool but provide does not allow to pool data across the studies that met
no evaluation data on patient outcome, the inclusion criteria. Characteristics and results of the
►► Studies that report a larger project in which SBAR studies are presented in a narrative form.
was not the main intervention under investigation
(because in such studies the attribution of any effect Patient and public involvement
to SBAR is impossible), No patients were involved in the design, recruitment or
►► Studies that only report, survey outcomes or team conduct of the study. The results of this review will not
perceptions. be disseminated to patients included in the trials of the
review.
Selection of studies
Studies were evaluated in two steps: (1) Two trained
reviewers (JJ, MM) reviewed all abstracts and titles for Results
eligibility. (2) If the eligibility of an article could not be Systematic review process
clearly determined, the article was included for further Article identification and inclusion is depicted in figure 1.
full-text evaluation in a second step. The literature search identified 1053 articles. Seven
In case of dissent, the reviewers solved the divergence hundred and one (701) articles remained after exclusion
by consensus or, if necessary, by involving a third reviewer of duplicates; 607 articles were excluded after reviewing
(MR). the titles and abstracts. Of the remaining 94 articles
analysed in full text, 11 articles were included into this
Data extraction review. The rater agreement on inclusion was ICC 0.90
The following data were extracted out of the included (95% CI 0.86 to 0.94). No additional studies were identi-
articles using a predefined form in Microsoft Excel for fied through screening of the references of the included
Mac 2011 (V.14.7.2; Microsoft, Redmond, Washington, articles.
USA): characteristics of the study (study setting, study
design and information to evaluate the risk of bias; see Quality assessment
below), characteristics of the study population and Rater agreement on the studies quality ratings was excel-
possible control group (type and number of trained lent (ICC 0.85, 95% 0.78 to 0.90).
people), characteristics of the intervention (type and The randomised controlled trial (RCT) by Field et al49
duration) and outcome data on patients’ safety including was rated as ‘strong’ and one controlled trial by Randmaa
time/period of measurement). To ensure high accuracy et al37 as ‘moderate’ in the overall study quality, while the
and completeness of the data extraction by MM and JJ, remaining nine studies were rated as ‘weak’ (figure 2).
data extraction was checked by KK. Three studies were rated as strong in the study design
category as they were controlled clinical trials.37 49 50 Eight
Quality assessment studies used a before–after study design resulting in a
Methodological quality of the studies included was weak rating in the study design category.
assessed with the ‘Quality Assessment Tool for Quantitative Except for the study by Christie and Robinson,41 in
Studies’ developed by the Effective Public Health Prac- which the selected individuals were not described in suffi-
tice Project Canada.46 The tool is recommended by the cient detail, the study quality regarding selection bias was
Cochrane Collaboration47 as it evaluates the full range of rated as ‘moderate’.
quantitative study designs. It has been evaluated for inter- The study by Field et al49 used a RCT as a design with
rater reliability, content and construct validity.48 The iden- facility as a randomisation unit. Thus, by study design,
tified studies were assessed on 18 criteria in six domains the results were controlled for potential (known and
(selection bias, study design, confounders, blinding, data unknown) confounders such as infrastructure, patient
collection methods, as well as withdrawals and drop-outs). safety culture and management.
Studies were rated as ‘strong’, ‘moderate’ or ‘weak’ in No other study controlled for confounders in the study
each domain. An accompanying algorithm consolidates design or analysis (weak rating).
the six ratings into an overall score. While main outcomes, study objectives and the applied
Two reviewers (JJ, MM) independently assessed the SBAR intervention were described in all studies, blinding
quality of each study. The final assessment of each study was not described in any but one of the studies (9.1%),
was determined by consensus between the two reviewers resulting in a ‘moderate’ rating in this category. In one of
and, if necessary, by involving a third reviewer (WEH). the controlled trials,49 the reviewers who rated the patient

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Figure 1  Flowchart of the systematic review process. SBAR, situation, background, assessment, recommendation. *No
additional studies were identified through screening of the references of the included articles.

safety outcome were blinded in regard to the intervention the intervention to specific units (anaesthesiological,50
(strong rating). surgical37 or medicosurgical54 55) while three trials intro-
Overall, there was a lack of reporting on statis- duced the SBAR tool to all departments.41 51 53 Nurses were
tical tests51–54 and number of persons that were trained in the use of SBAR in all studies. In five studies
trained.41 49 51 53–55 Sample size calculations to ensure suffi- (45.5%), additionally other clinical staff, for example,
cient power were not reported in any of the studies. physicians, were trained also.37 41 50–52 The number of staff
members trained ranged from 3850 to 15537, but was not
Study setting and study characteristics specified in five studies41 49 51 53 55 (online supplementary
Eight of the analysed studies (72.7%) used a before–after appendix B).
intervention design,41 51–57 while in two studies (18.2%) The study period was mainly dependent on the time
a non-RCT37 50 and in one study (9.2%) a RCT49 were period that the patient outcomes were measured and
reported. ranged between 250 and 24 months37 56 and was not speci-
All identified articles were published in recent years fied in two studies.41 53
(2006–2016). Eight (72.7%) of the 11 studies were
conducted in North America,49–54 56 57 and the remaining Intervention targets
three (27.3%) were performed in Europe.37 41 55 A detailed description of the wide range of implementa-
The studies focused on three different study sites: tion strategies of SBAR in the studies included is provided
(1) hospitals in seven studies (63.6%),37 41 50 51 53–55 (2) in online supplementary appendix C.
a rehabilitation centre (geriatric/musculoskeletal unit) In two studies (18.2%), the aim of the intervention was
in one study52 (9.2%) and (3) nursing homes in three to improve team communication in general51 52 while
studies (27.3%).49 56 57 Four of the studies that intro- five studies (45.5%) focused on patient hand-offs either
duced the SBAR tool into a hospital setting restricted between nurses or interprofessional.37 41 53 54 The four

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methicillin-resistant Staphylococcus aureus (MRSA) bacte-
raemias41 and catheter-associated urinary tract infection
rates.53
The duration of measurement of the patient outcomes
in the pre/controlled phase respectively the post/inter-
vention phase ranged from 1 month50 54 to 12 months37
and was not reported in three studies.41 52 53 Three of the
studies37 51 55 controlled the use of SBAR by staff survey or
review of medical records and identified high use rates
within daily routine.

Effect of SBAR on patient outcomes

Overall summary
The main study characteristics and the effects of SBAR on
the studied patient outcomes are summarised in table 2.
In total, 26 different patient outcomes were
measured. Of these, eight outcomes measured in five
studies37 49 54 55 57 significantly improved and 11 patient
outcomes measured in four before–after studies41 51–53 are
described as improving without the report of a statistical
test. Six outcomes did not change significantly. One study
descriptively reported an increase of adverse events,52
and none found a significant reduction of patient safety.
The reported results of the studies are shown in detail in
online supplementary appendix D.

Team communication in general

While one of the two before–after studies that focused
on team communication in general51 found a reduction
of adverse patient as well as of drug events, a study that
focused on falls in a rehabilitation centre52 found mixed
Figure 2  Quality assessment of the included studies.
results with a decrease in major falls, but an increase in
the incidence of overall falls. Both studies did not provide
remaining studies (36.4%) aimed to improve commu- a statistical analysis of their results.
nication in a particular situation such as telephone
calls between nurses and physicians for anticoagulation Patient hand-off
management49 or in case of patient deterioration.55–57 All but one50 of the five studies37 41 50 53 54 that focused on
Implementation strategies were educational programmes patient hand-offs reported an improvement of patient
(seven studies41 49 51 52 54–56), organisational/human support safety. Two before–after studies focused on patient
(seven studies37 41 49 51–54) and interactive teaching (seven hand-off between nursing shifts.53 54 A reduction in the
studies37 41 50 52 53 55 56) including group discussions and number of patient falls was reported in both studies. In
role play. Additional SBAR trigger tools (poster, pocket addition, restrained patients rate and catheter-associated
cards, telephone stickers) were used in six studies urinary tract infection rate decreased about one-third
(54.5%).37 41 49 51–53 in one of these studies.53 Both studies that focused on
patient hand-offs between physicians and nurses reported
Patient outcome an improvement in patient safety–related outcome.37 41
All studies included assessed the effect of SBAR implemen- In their controlled clinical trial, Randmaa et al37
tation on the outcome of inpatients, none the outcome of reported that the critical incidence reporting system
outpatients. The patient outcomes and outcome measure- (CIRS) events due to communication breakdowns in the
ments varied widely over the identified studies (online department of anaesthesiology of two clinics decreased
supplementary appendix D). Three studies (27.3%) significantly from 31% to 11%. The before–after study
measured general patient outcomes such as adverse performed in a hospital by Christie and Robinson41 found
patient/drug events,41 50 51 while the remaining eight a reduction in hospital mortality (−11%), MRSA bacterae-
studies (72.7%) used specific adverse event outcomes mias (−83%), adverse events (−65%) and cardiac arrests
such as anticoagulation-related49 and patient fall–related (−8%) after SBAR implementation (no further statistical
adverse events52–54 as well as unplanned events such as analysis reported).
ICU admissions,55 death/cardiac arrests41 55 and transfer The controlled clinical by Telem et al50 evaluated
to hospitals.56 57 Other patient outcomes included the effect of SBAR versus no-SBAR training on patient

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Table 2  Study characteristics and outcomes sorted by effect on patient safety, study design and year
Study Design Setting How SBAR was used Patient outcome defined as Effect
49
Field et al RCT Nursing home Telephone communication from INR values within the target ▲
2011 nurse to doctor—anticoagulation range
management
Randmaa et al37 CCT Hospital Patient hand-off—physician and CIRS events (communication ▲
2014 nurses errors)
De Meester et al55* BAS Hospital Telephone communication from (1) Unexpected death and (2) ▲
2013 nurse to doctor—deteriorating/status ICU admission
change of a patient
Pineda54 BAS Hospital Patient hand-of f—nurses Patient falls ▲
2015
Devereaux et al57 BAS Nursing home Telephone communication from (1) 30-day readmissions, (2) ▲
2016 nurse to doctor—deteriorating/status transfers to hospital and (3)
change of a patient avoidable hospitalisations
Haig et al51 BAS Hospital Team communication in general (1) Adverse patient and (2) drug △
2006 events
Andreoli et al52 BAS Rehabilitation Team communication in general (1) Falls severity (four levels), (2) △
2010 clinic near-miss reporting
Freitag and Carroll53 BAS Hospital Patient hand-off—nurses (1) Inpatient fall rate, (2) △
2011 restrained patients rate and (3)
catheter-associated UTI
Christie and BAS Hospital Patient hand-off— physician and (1) Hospital mortality, (2) △
Robinson41 nurses adverse events, (3) cardiac
2009 arrests, (4) MRSA bacteraemias
Field et al49 RCT Nursing home Telephone communication from Preventable AE related to ○
2011 nurse to doctor—anticoagulation warfarin therapy
management
Telem et al50 CCT Hospital Patient hand-off—physician Sentinel events ○
2011
De Meester et al55 BAS Hospital Telephone communication from Call of cardiac arrest team ○
2013 nurse to doctor—deteriorating/status
change of a patient
Jarboe56 BAS Nursing homes Telephone communication from (1) Overall number of transfers ○
2015 nurse to doctor—deteriorating/status to acute care hospitals, (2)
change of a patient types of transfers by clinical
condition criteria, (3) transfers
resulting in hospitalisation
Andreoli et al52 BAS Rehabilitation Team communication in general Falls incidence ∇
2010 clinic
If a study reported outcomes with different effects on patient safety, the study results are listed separately.
▲, statistically significant evidence for improvement; △, descriptive evidence for improvement (no statistical test reported); ○, no significant
evidence of a change; ∇, descriptive reduction of patient safety.
*And nursing hand-off (between shifts).
AE, adverse event; BAS, before–after study; CCT, clinical controlled trial; CIRS, critical incident reporting system; ICU, intensive care unit;
INR, international normalised ratio; MRSA, methicillin-resistant Staphylococcus aureus; RCT, randomised controlled trial; SBAR, situation,
background, assessment and recommendation; UTI, urinary tract infection.

hand-offs by physicians on surgical wards. The number patients.55–57 Two studies reported significant improve-
of identified sentinel events was not statistically different ments in the study patient outcome under investigation
between the study groups. One sentinel event was while the study of Devereaux et al57 could not find a signif-
reported over the whole study period. icant change.
Telephone communication between nurse and physician Field et al49 showed a statistically significant improve-
Three trials tried to increase the quality of telephone ment in the management of anti-coagulated patients in
communication between nurse and physician when nursing centres using a randomised controlled design:
nurses reported deterioration or other status changes of the international normalised ratio (INR) value of patients

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was 4.5% more time within the therapeutic range in the because warfarin is increasingly substituted by direct
intervention homes than in control homes (95% CI 3.1% oral anticoagulants less difficult to dose,60 the rele-
to 8.7%). They further reported a non-significant reduc- vance of this finding may cease over time. Furthermore,
tion of adverse warfarin-related events in the intervention adverse events related to warfarin therapy, the primary
homes (OR 0.9, 95% CI 0.5 to 1.4). outcome parameter in this study, did not differ signifi-
De Meester et al55 (before–after study) reported that the cantly between the intervention and control group. We
number of unexpected death was significantly decreased found further evidence that the use of SBAR in tele-
from 0.99 to 0.34 per 1000 admissions (p<0.001), while phone communication to inform the physician of a
ICU admissions increased (13.1 to 14.8 per 1000 admis- deteriorating patient leads to (1) a significant decrease
sions) without a significant difference in the frequency in unexpected death22 and (2) a significant reduction
with which a cardiac arrest team was called. in transfers to hospitals, 30-day readmissions and avoid-
Devereaux et al57 studied transfers from nursing homes able hospitalisations from nursing homes.21 Therefore,
to acute care hospitals using a before–after trial and SBAR implementation in telephone communication
found a significant reduction in 30-day readmissions seems to positively affect patient outcome. However, one
(0.12 vs 0.04, p=0.012) and avoidable hospitalisations study conducted in a similar setting56 (nursing home,
(0.15 vs 0.05, p=0.007). Jarboe56 used a similar setting, but unplanned hospital admission) but with a longer study
a longer study period (20 months vs 6 months) and could period could not find any significant difference between
not find significant differences with regard to preventable the preimplementation and postimplementation phase
patient transfers (p=0.927) or emergent patient transfer in the patient outcomes. One explanation for the differ-
(p=0.565). ences in the findings might be that the use of SBAR (not
reported in the two studies) decreased over time, thus
the effect vanished.
Discussion Study periods were short at least in two trials50 54
Summary of main results (2 months only). As a consequence, only one sentinel
The present systematic review assesses the effect of the event in one controlled clinical trial50 over the study
implementation of the widely adopted communication period was reported.
strategy SBAR on patient-related outcomes. Because Power calculations were missing in all studies. Thus,
communication breakdowns have been repeatedly iden- the lack of significant differences between the groups
tified as a major source of adverse events and medical in these studies could not be interpreted adequately.
error,4 58 59 implementation of a strategy such as SBAR Furthermore, in almost half of the reported outcomes,
seems a valid remediation approach. no statistical tests were performed. Notably, no study in
Eleven studies, eight with a before–after design and our review found a significant increase in the occurrence
three controlled trials, met the inclusion criteria. SBAR of adverse events after to the implementation of SBAR,
was implemented through different strategies in three but Andreoli et al52 descriptively reported an increase in
different clinical settings (hospitals, rehabilitation centre fall incidence while the fall severity was reduced at the
and nursing homes) and with a broad range of objec- same time. This study’s findings illustrate the difficulty
tives to improve (1) team communication in general, (2) with most of the studies findings included in the review.
intradisciplinary and interdisciplinary patient hand-offs, Some might argue that the implementation of SBAR in
and (3) communication in telephone calls from nurses patient fall reporting has just led to an increased aware-
to physicians. In total, 26 different patient outcomes ness regarding patient falls. Consequently, the reporting
were measured. Eight significantly improved, 11 were of patient falls and especially of less severe falls increased,
described as improving (but no further statistical test resulting in a decrease of the patient fall severity overall.
were reported), six outcomes did not change significantly It has been previously argued that downstream targets
and one study reported a descriptive reduction in patient of educational interventions (such as the implemen-
outcomes. Study outcomes with statistical evidence for tation of a specific communication strategy) are often
improvement included INR values within the target difficult to assess due to possible dilution of the effect of
range49 and unplanned transfers to hospitals57 in nursing any intervention.61 62 Indeed, implementation of SBAR
homes, as well as CIRS events due to communication may only directly affect communication among health
errors,37 patient falls,54 unexpected death and ICU admis- professionals, which in turn may or may not affect health-
sions55 in hospitals. The overall study quality was high or care conduct, which then may result in altered patient
moderate in two studies only; all other studies showed a outcome. Arguably, there are many other effective agents
weak study quality. along this path that may dilute the effect of SBAR imple-
mentation on patient outcome. We would argue that
Quality of the evidence because it has been possible in the past to relate adverse
The strongest evidence identified in our review comes events to communication breakdowns,7 58 59 it should just
from a single RCT investigating the effect of SBAR as well be possible to demonstrate the effect on patient
implementation in nursing homes on anticoagulation safety of interventions targeted at remediating such
management of patients under warfarin.27 However, communication breakdowns.

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One reason for the current failure to demonstrate safety outcomes. Four other before–after studies41 51–53
such effects may be that studies investigating the effect reported descriptive improved patient outcomes. On
of SBAR on patient outcome are mostly of limited quality the one hand, these findings emphasise the potential
and yield heterogeneous results. Many studies identified importance of implementation of SBAR in the clin-
were before–after studies. It is thus difficult to differen- ical practice to improve (1) telephone communication
tiate between changes attributed to the implementation from nurse to doctors in critical situations, (2) general
of SBAR and changes attributable to other factors that patient hand-off as well as (3) team communication in
had changed over time, such as increased awareness. general. However, the quality of the evidence is low and
Process measures in regard to parameters of communi- four studies49 50 55 56 reported no significant changes of
cation were not measured in any of the included studies, other relevant outcomes and even a descriptive increase
but several not included studies suggest an improve- of patient falls also.52 Best evidence was found in tele-
ment of communication through the implementation phone communication between nurses and physicians.
of SBAR.34–40 The lack of process measures within the This should raise awareness and demands future high-
included studies reduces internal validity and impedes quality research as the unreflected adoption of SBAR may
the interpretation of the present results with regard to paradoxically limit improvements in healthcare commu-
causation. Consequently, the unreflected adoption of nication because once a problem appears to be solved,
SBAR may paradoxically limit improvements in health- less research will be conducted on it.
care communication because once a problem appears to
be solved, less research will be conducted on it.
Conclusion
Limitations In summary, many authors claim that SBAR improves
This systematic review has some limitations. Efforts were patient safety. There is some evidence of the effective-
undertaken to identify all relevant trials to evaluate the ness of SBAR implementation on patient outcome, but
impact of SBAR implementation in clinical practice on this evidence is limited to specific circumstances such as
patient safety. Five well-known databases as well as the communication over the phone. Especially high-quality
references of the studies that met the inclusion criteria studies are lacking. Future studies are needed to further
were searched using an open search strategy. No grey liter- demonstrate the benefit of SBAR in terms of patient safety
ature was searched, thus trials could have been missed. and keep raising the awareness of communication errors.
Further, we did not contact any author to ask for raw data SBAR might be an adaptive tool that is suitable for many
to perform additional statistical analysis. Publication bias healthcare settings, in particular when clear and effective
could not be assessed leading to an important source of interpersonal communication is required.
bias. The heterogeneity of the data impeded a meta-anal-
ysis. This systematic review was conducted in accordance Acknowledgements  The authors want to thank the Gottfried und Julia Bangerter-
Rhyner-Foundation for their ad personam grant Young Talents in Clinical Research
with the Cochrane Collaboration standards using a vali- for MM.
dated tool for quality assessment of the identified studies.
Contributors  All authors contributed to the conception of the review, analysis and
Reliability of the study selection, data extraction and interpretation of the results and the final approval of the manuscript. Study design:
rating of the study quality was ensured using two indepen- MM, JJ, MR, WEH, SS. Literature search and assessment (acquisition of data):
dent reviewers. We did not differentiate the broad range MM, JJ, KK. Drafting the manuscript: MM, JJ, MR, WEH. Critical revision of the
of adverse events or sentinel events, but subsume them manuscript for intellectual content: MM, JJ, MR, KK, WEH, SS.
under patient safety/outcome in order to provide a first Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
insight into the relationship between SBAR and patient
safety. The inclusion criteria were restricted to trials that Competing interests  WEH has received payment from the AO Foundation Zürich
for educational consultations and congress invitations from Mundipharma Basel.
reported at least one ‘hard’ patient outcome parameter
to evaluate SBAR’s impact on patient safety. Evidence of Patient consent  Not required.
improvement of potentially ‘soft’ outcomes such as an Provenance and peer review  Not commissioned; externally peer reviewed.
increase in employee satisfaction21 22 and interdisciplinary Data sharing statement  There are no additional data available.
communication19 23 with improvements of the commu- Open access This is an open access article distributed in accordance with the
nication perception, interdisciplinary teamwork,29–33 Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
completeness41–44 and efficiency40 42 45 of the communica- permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
tion were not reported in this review. Last, trials in which properly cited, appropriate credit is given, any changes made indicated, and the use
SBAR was a minor component of a complex intervention is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
only were not included in this review. These trials may
contain potential evidence for an improvement of patient
safety through the implementation of SBAR.
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