The Institute of Medicine (1999) has estimated that as many as 98,000 people die in U.S. hospitals each year due to preventable medical errors. The Joint Commission (2004) reports that 72 percent of root causes identified during the reviews of sentinel events related to infant death and injury during delivery are attributable to communication failures. As a result, the Joint Commission (2008) has identified effective communication as one of its National Patient Safety Goals. Communication tools like SBAR (Situation, Background, Assessment and Recommendation) can help nurses focus communication to improve the effectiveness of information transfer. SBAR is especially important in urgent or high-acuity situations where clear and effective interpersonal communication is critical to patient outcomes.