Date of Award


Document Type

Independent Study

Degree Name

Master of Science (MS)


Missed medical orders and incorrect medication orders are part of the fundamental reasons for medication errors and sentinel events. Missed orders primarily arise from communication failure of both the messenger and the intended receiver. Much of the evidence that connects communication failure with missed or misunderstood orders and sentinel events comes from retrospective analyses of past sentinel events. This connection has been recorded in numerous parts of the world and is a topic worthy of exploration. This independent study examined retrospective analyses, a literature review, and evidenced based studies to determine how specific "communication issues" lead to errors. The author sought to identify interventions to address communication shortcomings with the best current evidence. The author specifically reviewed the use of Situational, Background, Assessment, and Recommendation (SBAR), a tool to improve communication. The SBAR tool can influence how healthcare providers share information and in turn increase the safety and improve the outcomes of patient care