Without structured training, how can you ensure participants correctly understood and applied each component of ISOBAR (e.g., what “S” or “B” entails)? Could there have been superficial adherence—mentioning keywords without meaningful content—that was not captured? How might this affect your measurement of adherence and the conclusion that adherence did not influence outcomes?
Does the observed improvement in KITE (e.g., from 8.29 to 8.61) translate to a clinically important difference? Was a minimal clinically important difference (MCID) established? Why were direct patient safety outcomes (e.g., adverse events, readmissions, diagnostic delays) not included as secondary endpoints to validate KITE’s predictive value?
If adherence does not influence outcomes, does this imply that any structured framework (or even a non-ISOBAR prompt) that raises awareness could yield similar benefits? Does this undermine the theoretical rationale for ISOBAR itself? Could your adherence measure (based solely on information sequence) have failed to capture deeper aspects of communication quality?
Were recall bias or social desirability bias (especially with the study team present) considered? Did you validate recalled information against medical records? Why was 15 minutes chosen over a more clinically relevant timepoint (e.g., after disposition decision)?
Does the decline in effect during post-intervention phases suggest that improvement was heavily reliant on ongoing prompts and the presence of the research team (Hawthorne effect)? How can sustained implementation be ensured without continuous oversight? Are multi-center or long-term follow-up studies planned to confirm robustness?