Aims Clear communication within a resuscitation team is paramount. This can break down when one team member recognises that the team leader may be making a poor decision, but is unsure how to address this. A number of models of ‘graded assertiveness communication’ are advocated, of which one is the ‘PACE’ system. Four escalating levels of intervention are used sequentially. We present a case of how graded assertiveness was used to redirect the management of a patient.

Methods A four year old with known Marfan’s syndrome was admitted under Paediatrics at a district general hospital, with acute onset breathlessness and cough. He was seen on the assessment unit by a consultant paediatrician, who found severe respiratory distress, hypoxia and no chest sounds on the right chest. The patient was moved to the resuscitation bay, and additional support was summoned. An urgent chest x-ray was requested, and excluded a tension pneumothorax. Based on the clinical findings and the short history of symptoms, the consultant explored the possibility of foreign body inhalation and proceeded to make contact with ENT and PICU at a tertiary hospital. At the same time a junior member of the team reviewed the history, re-examined the patient and found that although there were unequal breath sounds, there was also wheeze, and suggested that the patient would benefit from bronchodilators. The patient was reviewed by the consultant, who felt that bronchodilators would not help, and the picture was not one of small airways disease.

Results The junior proceeded to use graded assertiveness communication – Probe, Alert, Challenge and Escalate to redirect the management of this patient. The patient received bronchodilators and responded. He remained in the DGH over night and was discharged the following day.

Conclusion On reflection the team members recognised that this is an area of medicine that is potentially difficult and dangerous. Sharing such experiences and approaches widely would help all staff to feel empowered to use their skills and knowledge to avoid medical error that could have been predicted.