Failed ED-to-ICU handover — ISBAR and system fix

(a) Definition and failure. Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care and the accompanying information. This case failed by information omission (allergy; lactate trend) in what was likely a verbal-only, unstructured transfer without receiver readback/synthesis and without explicit confirmation of responsibility — the commonest root pattern of handover harm.^[1][2]

(b) ISBAR for this patient.

• I — Identify: patient name/UR, age; sending and receiving clinicians.
• S — Situation: septic shock transferred to ICU for vasopressors/monitoring; time-critical.
• B — Background: presentation, comorbidities, drug allergy (state agent and reaction), source of infection, treatments given including antibiotic choice and timing, relevant investigations.
• A — Assessment: current vitals, lactate trend (values and time points), working diagnosis, residual concerns (e.g. source control).
• R — Recommendation: the ask (continue antibiotics that are safe given allergy; recheck lactate; goals of care if relevant) with timeframe, then receiver synthesis/readback and explicit transfer of responsibility.^[1][2]

(c) System fix. Mandate structured tools (ISBAR/I-PASS) at high-risk transitions (ED→ICU) — a multicentre handoff programme cut medical errors and preventable adverse events while improving communication, without harming workflow.^[1] Add protected interruption-free handover; written checklist including allergies, critical results and outstanding tasks; closed-loop readback; audit; culture that flattens authority gradient; electronic mandatory allergy field visible at transfer.^[1][2]