Warfarin therapy is commonly associated with adverse events despite specific indicators designed to capture them and guide prevention efforts. This study adopted the SBAR communication tool as part of a protocol to improve the quality of warfarin management in the nursing home setting. Using a facilitated telephone communication between nurses and physicians in 26 nursing homes, the patients randomized to the SBAR approach had statistically significant improvements in their therapeutic levels and a non-statistically significant reduction in adverse events. A past AHRQ WebM&M commentary discusses a case of inadequate warfarin monitoring that resulted in an adverse event for a nursing home patient.