What is a sample SBAR (Situation, Background, Assessment, Recommendation) for a patient with an unwitnessed fall?

From the Research

Introduction to SBAR

The Situation, Background, Assessment, and Recommendation (SBAR) tool is a structured method for communicating critical information that requires immediate attention and action, contributing to effective escalation of management and increased patient safety 1, 2, 3, 4, 5.

Sample SBAR for a Patient with an Unwitnessed Fall

Situation

• The patient was found on the floor by nursing staff
• The patient is currently being assessed for injuries

Background

• The patient has a history of falls and has been experiencing dizziness and lightheadedness
• The patient is currently taking medications that may increase the risk of falls
• The patient's room is equipped with fall prevention measures, including a bed alarm and non-slip socks

Assessment

• The patient is alert and oriented, but reports hitting their head on the floor
• The patient has a visible bruise on their forehead and is complaining of pain
• The patient's vital signs are stable, but they are experiencing some confusion and disorientation

Recommendation

• Order a CT scan of the head to rule out any serious injuries
• Provide pain management as needed
• Continue to monitor the patient's vital signs and mental status
• Consider consulting with physical therapy to assess the patient's fall risk and develop a plan to prevent future falls
• Review the patient's medications and consider adjusting them to reduce the risk of falls
• Ensure that the patient's room is equipped with adequate fall prevention measures, including a bed alarm and non-slip socks

Key Considerations

• The SBAR tool should be used to communicate critical information that requires immediate attention and action 1, 2, 3, 4, 5
• The tool should be used in a variety of clinical and non-clinical situations, including transitions in care, debriefing, and conflict resolution 3
• Staff should be trained on the use of the SBAR tool and should be encouraged to use it to communicate relevant and succinct information 1, 2, 3, 4, 5
• The SBAR tool can be used to improve communication between professionals and to enhance patient safety 1, 2, 3, 4, 5

Treatment and Management

• The patient should be treated for any injuries sustained during the fall
• The patient's medications should be reviewed and adjusted as needed to reduce the risk of falls
• The patient should be provided with education on fall prevention and should be encouraged to use assistive devices, such as a walker or cane, as needed
• The patient's room should be equipped with adequate fall prevention measures, including a bed alarm and non-slip socks

Differentials and Caveats

• The patient's fall may be related to a variety of factors, including medications, medical conditions, and environmental factors
• The patient's assessment and management should be individualized based on their specific needs and circumstances
• The SBAR tool should be used in conjunction with other communication tools and strategies to ensure effective communication and patient safety 1, 2, 3, 4, 5