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MODULE 23: CLINICAL PHARMACY ON THE FLOORS: MASTERING PATIENT CARE ROUNDS
Section 23.4: SBAR in 60 Seconds: The Micro-Structure for Recommendations
From a collection of facts to a compelling clinical argument. This is the blueprint for constructing interventions that are impossible to ignore.
SECTION 23.4
SBAR in 60 Seconds: A Deep Dive
Mastering the universal language of patient safety to ensure your voice is heard and your recommendations are implemented.
23.4.1 The “Why”: From Information Chaos to Structured Clarity
In the complex, high-acuity environment of a hospital, communication failures are not a trivial matter; they are a primary root cause of catastrophic medical errors. A physician, nurse, or pharmacist might possess the single piece of information that could save a patient’s life, but if that information is not communicated effectively, it is as if it never existed. The challenge is that each discipline is trained to see the patient through a different lens and prioritize different types of data. A nurse might be focused on a patient’s vital sign trends and comfort. A physician might be focused on the differential diagnosis and the overall treatment strategy. You, the pharmacist, are focused on the intricate details of pharmacokinetics, drug interactions, and appropriate dosing.
When these different streams of information converge—as they do on rounds or in a phone call about a critical patient—the result can be information chaos. Important details can be buried in a long narrative, the core “ask” can be unclear, and the urgency of a situation can be lost in translation. This is the problem that SBAR was designed to solve.
SBAR (Situation, Background, Assessment, Recommendation) is not just a communication tool; it is a shared mental model for organizing and transmitting critical information. It was originally developed by the U.S. Navy for use on nuclear submarines, environments where a breakdown in communication could have unthinkable consequences. Its adoption into healthcare by organizations like The Joint Commission and the Institute for Healthcare Improvement is a recognition that patient safety is an equally high-stakes endeavor. For you, the transitioning pharmacist, mastering SBAR is the single most effective technique for translating your encyclopedic drug knowledge into clear, concise, and actionable clinical interventions. It is how you cut through the noise and ensure your expertise has maximum impact.
Retail Pharmacist Analogy: The Perfect Prescription Clarification Call
Think about the hundreds of clarification calls you’ve made in your career. You have likely, through trial and error, developed a highly efficient script for these calls. You don’t call a busy prescriber’s office and start with a long, rambling story. You have an implicit, structured system designed to respect their time and get a clear answer quickly. That system is, in essence, SBAR.
Let’s deconstruct one of your effective calls:
- (S)ituation: “Hi, this is [Your Name], the pharmacist at [Your Pharmacy], calling for Dr. Jones regarding a new prescription for the patient John Doe, date of birth 1/1/1950.” (You immediately identify who you are, who you’re calling about, and the subject.)
- (B)ackground: “Dr. Jones prescribed lisinopril 20mg daily, but my records show Mr. Doe has a documented angioedema reaction to ramipril.” (You provide only the essential context that makes the situation understandable and serious.)
- (A)ssessment: “Because of the cross-reactivity risk with ACE inhibitors, I believe it would be unsafe to dispense this prescription.” (You state your professional conclusion about the situation.)
- (R)ecommendation: “Would you like to consider an ARB instead, perhaps losartan 50mg daily, as a safer alternative?” (You provide a specific, actionable solution.)
This entire, highly effective call takes less than 60 seconds. It is structured, clear, and professional. You already know how to do this. You have been using the principles of SBAR your entire career. The only shift is learning to apply this same rigid, safety-focused structure to your verbal recommendations on rounds and to your other interprofessional communications within the hospital.
23.4.2 Deconstructing SBAR: A Masterclass for Pharmacists
SBAR is a four-part harmony. Each component has a distinct purpose, and when they are performed in sequence, they create a compelling and easy-to-understand clinical narrative. To truly master the tool, you must understand not just what each letter stands for, but what its specific function is from a pharmacist’s perspective, what to include, and—just as importantly—what to leave out.
S = Situation: The Headline
The ‘Situation’ is your opening statement. It is a single, concise sentence that immediately orients the listener. It must answer the questions: “Who am I talking about?” and “What is the general subject of this communication?” This is your chance to grab the team’s attention and frame the entire conversation. It should be a headline, not the full story.
Mastering the “S” Statement
| Context | Weak “S” Statement (Vague & Inefficient) | Strong “S” Statement (Clear & Direct) |
|---|---|---|
| Making a recommendation on rounds. | “So for Mr. Williams in room 301, I was looking at some things…” | “For Mr. Williams in 301, I have a recommendation regarding his antibiotic therapy.” |
| Calling a physician about a critical lab value. | “Hi Dr. Evans, this is the pharmacist. I’m calling about one of your patients.” | “Dr. Evans, this is [Your Name], the pharmacist, calling about your patient Sarah Gordon in room 512 regarding a critical potassium level.” |
| Flagging a potential issue during table rounds. | “I have a question about the medications for the next patient.” | “Before we move on from Ms. Davis, I’ve identified a significant drug interaction with the new order.” |
The takeaway: Your “S” statement must be laser-focused. State the patient’s name and the general topic (e.g., “his anticoagulation,” “her pain management,” “a critical lab”). This allows the listener to immediately access the correct “mental file” for that patient and prepares them for the information that is about to follow.
B = Background: The Essential Context
The ‘Background’ is where you provide the minimum necessary clinical context for the listener to understand the problem. This is the most common place where SBAR communication breaks down. The temptation is to give a full patient history, but this is a critical error. You must be ruthless in editing the background down to only the data points that are directly relevant to your assessment and recommendation. The question to constantly ask yourself is: “Does the listener absolutely need to know this piece of information to understand my point?”
Mastering the “B” Statement: A Case-Based Approach
| Clinical Scenario | Excessive Background (Information Overload) | Concise & Relevant Background (Effective) |
|---|---|---|
| Concern: A patient on warfarin has a critically high INR. | “Okay, so this is an 82-year-old male with a history of hypertension, diabetes, GERD, and osteoarthritis who was admitted three days ago for a COPD exacerbation. He’s been getting steroids and nebulizers. His diet has been poor. He also has A-Fib, which is why he’s on warfarin at home…” | “He is on warfarin for atrial fibrillation. He was started on a course of levofloxacin for his pneumonia two days ago. His baseline INR on admission was 2.5.” |
| Concern: A patient with renal dysfunction is on an inappropriate dose of an antibiotic. | “This is a 65-year-old female admitted for cellulitis. She has a history of two prior MIs and has a stent. She is also diabetic and takes metformin at home, which we are holding. She’s getting IV vancomycin for her cellulitis. Her blood pressure has been a little soft…” | “She was started on vancomycin for cellulitis. Her serum creatinine has been rising over the past 48 hours, from a baseline of 1.5 to 2.8 this morning.” |
The takeaway: The ‘Background’ is not a summary of the patient’s entire hospital course. It is a curated set of 2-3 key data points that directly support the ‘Assessment’ you are about to make. Think of it as presenting only the most crucial pieces of evidence in a court case.
A = Assessment: Your Professional Conclusion
The ‘Assessment’ is the cognitive core of your SBAR. This is where you connect the dots between the Situation and the Background. You are not just reporting data; you are interpreting it and stating your professional conclusion. This is your “so what?” statement. It is the single most important part of the SBAR, as it demonstrates your clinical judgment and adds your unique value as a medication expert.
Mastering the “A” Statement
| Scenario | Weak “A” Statement (Just reports data) | Strong “A” Statement (Interprets data & states conclusion) |
|---|---|---|
| Patient with high INR on warfarin and a new antibiotic. | “His INR today is 8.2.” | “His INR of 8.2 is critically elevated, most likely due to a significant drug interaction with the new levofloxacin. He is at a very high risk for a major bleed.” |
| Patient with rising creatinine on vancomycin. | “Her creatinine is up to 2.8 this morning.” | “Her rising creatinine indicates a significant acute kidney injury, which is likely being exacerbated by the vancomycin. The current dose is now unsafe.” |
| Patient with uncontrolled pain on PRN opioids. | “The patient used his PRN morphine six times in the last 24 hours.” | “His frequent use of PRN morphine shows that his underlying pain is not adequately controlled with the current regimen. We are chasing the pain instead of staying ahead of it.” |
The takeaway: Never skip the ‘Assessment’. Simply stating data and then jumping to a recommendation forces the listener to do the mental work of connecting the dots. Your job is to do that work for them. Clearly state what you think the problem is. This is where your clinical expertise shines.
R = Recommendation: The Actionable Plan
The ‘Recommendation’ is the final, critical step. It is your clear and specific “ask.” What do you want to happen next? A vague or non-specific recommendation is a common failure point that often results in no action being taken. The team is looking to you for a solution, not just a problem. You must provide one that is concrete, specific, and actionable.
Mastering the “R” Statement
| Scenario | Weak “R” Statement (Vague & Unhelpful) | Strong “R” Statement (Specific & Actionable) |
|---|---|---|
| Patient with high INR on warfarin. | “We should do something about his warfarin.” | “I recommend we hold his warfarin for the next two days, give 2.5 mg of oral Vitamin K now, and recheck his INR in the morning.” |
| Patient with AKI on vancomycin. | “We need to change the vancomycin dose.” | “I recommend we switch her antibiotic from vancomycin to daptomycin, which is not nephrotoxic, at a dose of 6 mg/kg.” |
| Patient with uncontrolled pain. | “We should probably add something for pain.” | “I recommend we start a scheduled long-acting agent, like morphine ER 15 mg every 12 hours, and continue the PRN morphine for breakthrough pain.” |
Closing the Loop: The Final Step of a Recommendation
A great recommendation doesn’t just end with the plan. It ends with a clear offer to help execute that plan. This is called “closing the loop.” It demonstrates teamwork and ensures the recommendation is actually implemented.
After stating your specific recommendation, add one of the following phrases:
- “Would you like me to pend that order for you?”
- “I can write the order for you to sign.”
- “I’ll follow up on that post-dialysis level this evening and get back to you with a dosing recommendation.”
This simple step transforms you from a consultant into a collaborative partner and significantly increases the likelihood that your recommendation will be put into action.
23.4.3 SBAR in Action: A Case-Based Masterclass
Let’s put all the pieces together. We will walk through several common clinical scenarios and construct the ideal SBAR communication for each. This will demonstrate how the framework is adapted for different types of problems and different levels of urgency.
Scenario 1: Antimicrobial Stewardship on Rounds
Patient: 70 y/o male on hospital day 5 for HCAP, empirically started on piperacillin-tazobactam and vancomycin. He is clinically improving, afebrile, with a down-trending WBC. You’re at table rounds with the hospitalist.
Pharmacist’s Pre-Work: You checked his microbiology this morning. Sputum cultures from admission finally resulted and are growing only *Pseudomonas aeruginosa*, which is sensitive to piperacillin-tazobactam, and resistant to levofloxacin. No MRSA was isolated.
The SBAR Intervention Script
(S)ituation: “For Mr. Henderson in 603, I have a recommendation for his antibiotic regimen based on his new culture results.”
(B)ackground: “He has been on broad-spectrum coverage with vancomycin and piperacillin-tazobactam for hospital-acquired pneumonia for five days. His sputum culture results are now final.”
(A)ssessment: “The culture grew only Pseudomonas, which is sensitive to his current piperacillin-tazobactam. No MRSA was isolated, so the vancomycin is providing no additional benefit and is putting him at unnecessary risk for nephrotoxicity.”
(R)ecommendation: “I recommend we discontinue the vancomycin and continue the piperacillin-tazobactam as monotherapy. We should also define a total duration; I suggest a 7-day course, meaning he has two days left. I can pend the order to discontinue the vancomycin for you.”
Scenario 2: IV to PO Conversion on a Teaching Service
Patient: 45 y/o female with a history of Crohn’s disease admitted for a non-severe diverticulitis. She is on hospital day 3, receiving IV ciprofloxacin and metronidazole. You are on walking rounds with the full teaching team.
Pharmacist’s Pre-Work: You review her chart. Vitals: Tmax 37.5°C. Labs: WBC down to 9.5 from 16. Notes: Nursing note indicates she is tolerating a soft diet well without nausea or vomiting.
The SBAR Intervention Script (Framed as a question)
After the intern presents the plan to “continue IV antibiotics,” you wait for the pause.
(S)ituation: “I have a question about the antibiotic plan for Ms. Albright.”
(B)ackground: “She’s been afebrile for over 24 hours, her white count has normalized, and she’s tolerating a diet.”
(A)ssessment: “Based on our hospital’s criteria, she appears to be an excellent candidate for conversion to oral antibiotics.”
(R)ecommendation: “Do we think it would be reasonable to switch her from IV ciprofloxacin and metronidazole to their oral equivalents today? This could help facilitate an earlier discharge.”
Scenario 3: Urgent Phone Call about an Interaction
Patient: 80 y/o male in the cardiac step-down unit for management of new-onset atrial fibrillation. The team just started him on amiodarone and his home dose of simvastatin 40mg was continued on admission.
Pharmacist’s Action: You are verifying the morning’s orders and you see this combination. You know that amiodarone is a strong CYP3A4 inhibitor and significantly increases the concentration of simvastatin, putting the patient at high risk for rhabdomyolysis. This is too urgent to wait for rounds tomorrow. You must call the prescribing resident now.
The SBAR Phone Call Script
(S)ituation: “Hi Dr. Chen, this is [Your Name], the pharmacist covering the step-down unit. I’m calling about your patient, Robert Frost in room C415, regarding a critical drug interaction.”
(B)ackground: “I see you’ve just started Mr. Frost on amiodarone for his new atrial fibrillation, and his home dose of simvastatin 40mg was also continued.”
(A)ssessment: “Amiodarone is a potent inhibitor of simvastatin’s metabolism, which can increase the risk of statin-induced myopathy and rhabdomyolysis by several fold. The combination of these two agents at these doses is contraindicated.”
(R)ecommendation: “To mitigate this risk, I recommend we either decrease the simvastatin dose to a maximum of 20mg daily, or preferably, switch him to a statin that does not have this interaction, like pravastatin 40mg daily. The latter is the safest option. I can pend an order to discontinue the simvastatin and start pravastatin for your signature.”
