Clinical handover and communication

Manage now— do this, in order

• Use one fixed framework in the same order every time — ISBAR: Identify (your name and role, the patient with one unique identifier, and the receiver's name and role written down), Situation (the problem, now, in one sentence, with your concern stated explicitly), Background, Assessment, Recommendation — then read-back. End every handover with "What have I missed?"
• B and A carry the content: background — onset and duration, relevant history, allergies, anticoagulants, insulin, steroids, immunosuppressants and traditional preparations, what has been given and when, and the trend of observations; assessment — your interpretation, the differential not yet excluded and what you do not know.
• R is a contract: precisely what you want, from whom, by when ("I need him reviewed within 15 minutes"), the ceiling of care, and the escalation trigger as an explicit conditional — "if the systolic falls below 90 mmHg or he becomes drowsy, do X". Close every loop: the receiver repeats the plan, doses and triggers in their own words and the sender confirms aloud.
• Present the caseload in order of acuity, not by bed number, and transmit six items for every patient: physiological state with score and trend; working diagnosis and what has NOT been excluded; outstanding tasks with a named owner and a clock time; pending results with the time sent and who will review them; ceiling of care and resuscitation status with who decided it and when; and an escalation trigger as a conditional. Resolve rather than transmit anything completable — an unread ECG is unfinished work, not a handover item.
• Give every verbal or telephone drug order as drug, dose, route, time — read back in full, confirmed aloud, and transcribed into the chart at the first opportunity. Never abbreviate units as "U" or "IU" (say "six units — six, units"); for potassium chloride state concentration, total dose, diluent volume and infusion duration, and never give it undiluted.
• Adrenaline — state the concentration, never the ratio alone, because the two are given by different routes at different doses: anaphylaxis (1 mg/mL, 1 in 1000) — adult 500 micrograms (0.5 mL) IM into the anterolateral thigh, repeat after 5 minutes if needed; under 6 years 150 micrograms (0.15 mL) IM, 6–12 years 300 micrograms (0.3 mL) IM, over 12 years 500 micrograms IM. Cardiac arrest (100 micrograms/mL, 1 in 10 000) — adult 1 mg (10 mL) IV every 3–5 minutes; child 10 micrograms/kg IV.Doctor / Nurse
• Calcium gluconate 10% for hyperkalaemia with ECG change: adult 10 mL IV over 5–10 minutes, repeated until the ECG normalises; child 0.5 mL/kg IV (maximum 20 mL) — the read-back must state the salt (gluconate versus chloride), the volume and the duration. Glucose for hypoglycaemia: adult 100 mL of 20% glucose IV or 50 mL of 50% glucose IV, recheck at 10 minutes; child 2 mL/kg of 10% glucose IV — 50% glucose must not be given to a child peripherally.Doctor / Nurse
• For any weight-based paediatric order the read-back must include weight in kilograms, the mg/kg dose, the total milligrams, the volume in millilitres and the route — a tenfold error in a mg/kg calculation is the classic paediatric drug death. Where a child has not been weighed, transmit the estimate, the method, and the fact that it IS an estimate — weight (kg) = (age in years + 4) x 2 for ages 1–10 — and never let two different weights circulate simultaneously.
• When a concern is not acted upon, escalate the FORM of the message, not its volume: probe, alert, challenge, emergency (PACE) or "I am Concerned, I am Uncomfortable, this is a Safety issue" (CUS) — and under the two-challenge rule, a concern stated twice without acknowledgement means you are expected, not merely permitted, to take the matter further. Urgency must be conveyed by direct spoken communication — written or messaged urgency is regularly missed.