Chain of Command - MCIC Vermont Patient Safety Documents

SUPPLEMENT A
Risk Analysis
Risk and Quality Management Strategies 19
Chain of Command
In healthcare, chain of command has been defined as a
“specific course of action involving administrative and
clinical lines of authority established to ensure effective
conflict resolution in patient care situations.” 1 Appropriate
chain-of-command policies and procedures are crucial
to patient safety in all healthcare settings, but
especially in acute care institutions and facilities where
patients are most at risk for an acute condition to develop
or where an emergency situation is likely to arise and require
intervention. In its Risk Management Program Development
Tool Kit, the American Society for Healthcare Risk
Management (ASHRM) recommends that organizations
develop policies and procedures on chain of command
for intervention during “any event or situation that does
not meet established guidelines or which may place a patient
at risk.” 2
Indeed, improvement and strengthening of the chain
of command was cited as a key component of a measurable
and successful effort to improve systems and processes
related to patient safety at a large tertiary hospital. 3
Some of the results of this overall effort included a reduction
in adverse drug events, as well as in ventilatoracquired
pneumonias and central-venous catheter-related
blood stream infections. The effort also resulted in a significant
decrease in the registered nurse vacancy rate. 4
Because the delivery of patient care at times involves
differences of opinion and conflicts in clinical practice,
healthcare institutions must provide a means of resolution
for the individuals involved in order to provide safe
care to patients. This Risk Analysis explains the purpose
of a chain-of-command policy and offers recommendations
for policy content, describes the conditions under
which chain of command should be invoked, reviews liability
claims involving chain of command, and proposes
strategies for implementing a chain-of-command policy.
Purpose of a Chain-of-Command
Policy
Differences in professional knowledge and skill levels,
as well as differences of opinion, can contribute to patient
care conflicts between physicians and hospital staff.
While the physician bears the responsibility for medical
decision making, other members of the healthcare team,
such as nurses, have a duty of care that includes advocacy
for the patient. Nurses in particular are held professionally
accountable for their own actions and have a duty to
intervene when medical care does not appear to meet the
standard of care.* This is especially true in hospitals and
other healthcare facilities where clinical situations often
compel caregivers to act quickly and decisively to meet
the patient’s needs. Failure to do so can constitute a
breach of duty and consequent patient harm and result in
a legal determination of negligence. (For related information,
see the Risk Analysis “An Overview of Nursing Liability,”
located elsewhere in your Healthcare Risk Control
[HRC] System.) Indeed, liability claims against healthcare
facilities often result from failed chain-of-command.
The purpose of a chain-of-command policy is to
• resolve a conflict involving patient care,
• clarify a care management plan,
• obtain a necessary patient care intervention,
* The term “standard of care” is a legal term of art that differs among
jurisdictions. Generally, the standard of care is the duty to treat patients
with the reasonable diligence, skill, competence, and prudence as is
practiced by minimally competent professionals in the same specialty
or general field of practice. (For more information on this topic, see the
Risk Analysis “A Legal Primer,” located elsewhere in your Healthcare
Risk Control System.)
HRC TOOLS FOR THIS TOPIC
The following tools and resources on this topic are
available in your HRC System. Refer to this article, your
HRC Index, the HRC Members’ Web site, and other HRC
resources for help.
— Case Law
— Sample Policy
— Action Recommendations
— Also Available on HRC Web Site
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2 Healthcare Risk Control
Failure to Pursue Physician Bedside Evaluation
A 70-year-old female patient with asthma who was
hospitalized for major depression on a psychiatric unit
developed progressive respiratory difficulties leading
to acute respiratory failure that necessitated intubation
and admission to the intensive care unit (ICU). She ultimately
recovered after several weeks of hospitalization
and rehabilitation following discharge.
Allegations in a liability suit brought by the patient included
failure to monitor, failure to timely contact the
physician, and failure to take aggressive action. The
case was settled before trial by the hospital and the physician.
The sequence of events is summarized below.
• At 7 p.m. on the second day of her psychiatric admission,
the patient developed shortness of breath and
expiratory wheezing, unrelieved by her Proventil inhaler.
Also, mild edema of the right ankle had increased
significantly from earlier in the day.
• At 7:30 p.m., the covering medical physician was
notified and the patient was treated with a diuretic
and a nebulizer, which were ineffective.
• At 10:30 p.m., oxygen was applied and Ativan was
administered, which were also ineffective, as the
patient stated that she could not breathe.
• At 11:30 p.m., the physician was notified and arterial
blood gases (ABGs) were ordered, as were additional
respiratory treatments, and then repeat
ABGs. Initial ABGs showed hypercarbia and hypoxia,
but following the respiratory treatments, the
levels improved slightly.
• Although tachypnic, the patient calmed down and
rested between 1 and 3 a.m.
• At 3:30 a.m., the patient again experienced respiratory
distress and the physician was again notified.
Sketchy documentation and missing records make
it difficult to ascertain what, if any, interventions
took place until another nursing entry an hour later,
at 4:30 a.m., when the patient was described as being
diaphoretic and having increased respiratory
distress.
• At 5:30 a.m., the physician was called again. The patient
was taken to the emergency department where
she was intubated during cardiopulmonary arrest,
stabilized, and then transferred to the ICU.
HRC Commentary: When the patient’s condition was
clearly becoming worse and the physician did not come
in to evaluate her, the psychiatric unit nurses and staff
had a duty to aggressively pursue bedside medical
evaluation. Additional calls to the physician were warranted
in this case, as was utilization of the chain of command
as necessary to obtain medical examination by a
physician. Instead, the patient was allowed to remain in
distress for several hours, which delayed appropriate
management of her respiratory distress. The physician
also under treated the patient at the time of the second
notification at 11:30 a.m., when drug therapy (steroids,
inhaled beta agonists, etc.) was indicated.
• provide for patient advocacy in the institution,
• support patient safety by maintaining the standard of
care, and
• support risk management by mitigating liability
exposures.
Chain of command should be used to affect a necessary
intervention for a patient’s well-being if the responsible
provider is delayed or is unable or unwilling to
intervene. 5 Chain of command should also be used when
the provider’s response or intervention is inappropriate
to the degree of urgency dictated by the patient’s condition
or when treatment is ineffective over time and the
provider does not present to personally examine the patient.
The scenario described in “Failure to Pursue Physician
Bedside Evaluation” outlines the sequence of
events in one case that demonstrates failure to use the
chain of command.
Communication, Culture, and Role
Conflict
Chain-of-command policies may be unused or underused
for many reasons, including nursing staff’s reluctance
for fear of causing trouble, a fear of the consequences
of going over someone’s head, or a lack of knowledge and
understanding of how to use the policies. 6 The involved
caregivers should make the initial attempts to settle patient
care conflicts through direct communication. But at
times, this is more easily said than done.
Difficulties in communication and collaboration between
physicians and nurses have long been documented
7 and continue to be the subject of much study and
debate. 8 Communication problems can plague physician-nurse
relationships and negatively affect patient
care. In a study of timely treatment of lower respiratory
infections in nursing home residents, delays in treatment
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Risk and Quality Management Strategies 19 3
of acute infection were found to be partially rooted in a
lack of confidence by physicians in the quality of nurses’
assessments, which stemmed from physicians’ dissatisfaction
with the way nurses communicate information
about the residents’ clinical status. 9 Another study of patient
outcomes in intensive care units found that the
greatest determinant of severity-adjusted death rates was
how well nurses and physicians worked together in planning
and providing patient care. 10 The need for teamwork
and communication in healthcare was also addressed in
the Institute of Medicine’s landmark 1999 report on errors
in medicine. 11
Perhaps the worst type of communication breakdown
occurs when a nurse or other health professional fails to
provide the physician with important patient information
because he or she believes it will not be addressed.
Failure to inform the physician about a patient’s condition
may breach professional practice standards, result in
disciplinary action for failure to follow institutional policies,
place the patient at risk of harm or result in actual
harm, and constitute negligence.
Perhaps the worst type of communication
breakdown occurs when a nurse or other health
professional fails to provide the physician with
important patient information because he or she
believes it will not be addressed.
Hospital cultures that do not support teamwork and
collaboration between disciplines, departments, and personnel
present obstacles to safe patient care by inhibiting
open communication and trust. 12 Traditional hospital hierarchies
that place bedside caregivers at the bottom and
physicians at the top can foster intolerance for nonphysicians’
input into plans of care, devalue the contribution
of nurses and other healthcare workers, and allow the
normalization of the use of inappropriate actions or
words by those in authority. Alarmingly, this type of
“culture of disrespect” was recently uncovered in U.S.
hospitals through a survey conducted by the Institute for
Safe Medication Practices (ISMP). The survey revealed
that nurses, pharmacists, and other healthcare workers
commonly reported intimidation and abuse. 13 Almost
half of the ISMP survey respondents said that the “intimidating”
behaviors of physicians and others had an effect
on how they questioned or clarified potentially inappropriate
medication orders. They either followed the order
despite their concerns or asked another practitioner to
question the order rather than interact with an intimidating
prescriber.
Clearly, a hospital environment that allows the use of
condescending language, impatience with questions,
and reluctance or refusal to answer telephone calls detracts
from patient safety. Hospital managers and
providers should consider correcting such an environment
a high priority. Chain-of-command policies cannot
be effective if the individuals who are expected to follow
them feel uneasy about carrying out the steps that should
take place even before invoking the chain of command —
namely, communicating concerns about patient conditions,
obtaining necessary medical orders and interventions,
and questioning or clarifying potentially unsafe
medical orders on behalf of patients. For more information
on patient safety and communication, see the Risk
Analysis “Communication” located elsewhere in your
HRC System.
Setting the Stage for Chain of
Command
Development of a new policy or revision of an existing
policy on chain of command is ideally preceded by an assessment
of the organization’s culture of safety. As noted
above, a work environment in which intimidation is
pervasive or where significant obstacles to frank communication
exist is not conducive to a meaningful chain-ofcommand
policy. Survey tools to assess the safety culture
have been validated as useful in evaluating hospital staff
perceptions of the ability to openly communicate and assert
themselves in identifying unsafe patient care situations,
work in teams, and report medical errors. 14 Safety
culture surveys typically ask staff members to respond
by agreeing or disagreeing with the types of sample statements
listed below:*
• Senior managers at my facility communicate to me
that patient safety is a high priority.
• Individuals are supported for reporting medical
errors.
• I work in an environment in which I can openly express
my opinions about patient care.
• The quality of communication between caregivers on
my unit is a hinderance to safe care on my unit.
• My organization has a clear process for handling disagreements
with the safety of an order.
* Sources for sample statements include Allina Medical Center’s patient
safety culture survey, posted under “Sample Policies” at the HRC
Members’ Web site (http://www.ecri.org); examples of questions
asked on patient safety rounds in the box in “Improving patient safety:
from rhetoric to reality,” in the October 2003 Risk Management Reporter;
and the Institute for Safe Medication Practice (ISMP) Workplace Intimidation
Survey, available from Internet at http://www.ismp.org/
Survey0311.asp.
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4 Healthcare Risk Control
• The process for handling clinical disagreements allows
me to bypass the prescriber or my supervisor if
necessary.
If the underlying milieu is found to be unsupportive
of teamwork and interprofessional communication,
leadership should make efforts to improve communications
and enhance the culture of safety. Leadership backing
is crucial to such efforts and may involve a
unit-specific approach. 15 Culture-of-safety survey results
that indicate a need to improve communication and
teamwork can garner leadership support and, thus, allocation
of the resources necessary to improve the culture
of safety.
Crew resource management, an approach to team
building and assertive communication in healthcare that
was adapted from a military model, is being used to enhance
communication and improve the culture of safety
in hospitals. (See “Crew Resource Management Encourages
Assertion in Healthcare.”)
The risk manager can also gain leadership support for
clear chain-of-command policies by providing information
on liability claims that exemplify how the lack of (or
failure to invoke) chain-of-command policies affected patient
outcomes and/or ability to defend the claims. The
risk manager would also play a key role in conducting
safety culture surveys and in providing education about
Crew Resource Management Encourages
Assertion in Healthcare
One approach to breaking down hierarchies, fostering
assertive communications, and building teams currently
being tested in healthcare came from the U.S.
Department of Defense. Instituted by the U.S. military
after numerous aircraft crashes, crew resource management
(CRM) makes everyone responsible for flight
safety and focuses on communication, stress management,
and other human-factors concepts to prevent
aviation mishaps. 1 With CRM, if a problem is detected,
all team members are held accountable for fixing the
problem or, if the problem is not within their realm, for
notifying someone who can fix it.
CRM has been adapted for use in military medicine
and renamed “Medical Team Management.” 2 Other
adaptations of the CRM concept include the Operating
Room Human Factors Project 3 and emergency department
MedTeams. 4 One important and similar aspect
of these programs is that all team members are urged
to speak up when there is a problem, and the leader(s)
are expected to listen. Everyone is taught respectful assertion.
Other features of these programs include education
in team building and communication through
role playing and implementing “briefings.” A briefing
is the direct communication between physicians,
nurses, or other care givers on patient status that includes
transfer of important patient information at
critical times such as prior to before the start of a procedure,
at the change of shift, or during morning
rounds.
The crux of good communication skills that forms
the foundation of CRM is for all team members to use
and understand well-defined language. 5 Using a predetermined
way of communicating that there is a
problem reduces misunderstandings and increases
appropriate interventions to correct the problem. Everyone
on the team recognizes that with this type of
communication, they must pay attention, listen, and
act. CRM can prevent communication breakdowns
through team building, reducing the need to invoke
the formal chain of command to obtain necessary patient
care. Clear communication and improved patient
safety can be the most direct benefits of CRM. 6
Notes
1. Stone FP. Medical team management: using teamwork to
prevent medical errors [online]. Legal Medicine 2001 [cited
2004 Jun 9]. Available from Internet: http://www.afip.
org/Departments/legalmed/legmed2001/medical.htm.
2. Ibid.
3. University of Texas Center of Excellence in Patient Safety
Research. Research into medical human factors and human
error in medicine [online]. [cited 2004 Jun 11]. Available
from Internet: http://homepage.psy.utexas.edu/
homepage/group/HelmreichLAB/Medicine/medicine.
html.
4. Dynamics Research Corporation. MedTeams products
and services [online]. [cited 2004 Jun 11]. Available from
Internet: http://www.drc.com/TrainingAnalysis/
products.htm.
5. Crew resource management promises adverse events.
Healthc Risk Manage 2003 Sep;25(9):103-5.
6. Ibid.
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Risk and Quality Management Strategies 19 5
the benefits of open communication and the importance
of chain of command to managers, providers, and staff.
Chain-of-Command Policies
The lack of a proper chain-of-command policy and/or
the failure to follow an existing chain of command is often
among the allegations in negligence cases. When patient
care issues cannot be resolved between the individuals
involved, a clear administrative process must be available
to resolve the conflict(s) in the interest of safe patient
care. This administrative process should be outlined in a
chain-of-command policy, communicated to physicians
and hospital personnel, and supported by facility leaders
who demonstrate its importance through their interactions
with providers, patients, and staff. A sample policy
on chain of command is reprinted in the Appendix.
In reality, communication flows in both
directions, as well as back and forth between
departments and disciplines, in the process of
resolving issues and clarifying exactly what
actions should be taken.
Often depicted in a bottom-up diagram, the chain of
command depicts positions or personnel in a hierarchical
flow of communication. (See “Sample Chain-of-
Command Schematic.”) In reality, communication flows
in both directions, as well as back and forth between departments
and disciplines, in the process of resolving issues
and clarifying exactly what actions should be taken.
For example, suppose a physician orders that a drug be
given to a patient but the nurse knows that the drug is
contraindicated or could be dangerous if given to the patient.
The nurse has a professional duty to question the
drug order and convey his or her concerns to the physician.
Upon notification, if the physician does not change
the order and/or insists that it be administered to the patient,
according to the specified chain of command, the
nurse should notify the appropriate supervisor or other
clinical manager. The onus is then on the manager to intervene
with the physician about the drug order. If the
situation cannot be resolved at that level, the manager or
primary nurse must continue up the chain and contact the
medical director, department chairperson, or other designated
clinician as necessary to ensure the patient’s
safety. All the while, there should be ongoing communication
between the primary nurse and the responsible
managers.
Policies on chain of command should also set forth the
conditions under which the policies should be initiated.
Such conditions include those that jeopardize patient
care and safety, such as
• conflicts concerning the plan of care,
• unclear or potentially unsafe orders,
• unavailability or unresponsiveness of the care
provider(s), and
• unprofessional behaviors.
An example of how the chain of command can be used
to prevent a potential adverse outcome is illustrated in
the following situation. 16 An order for an abdominal computed
tomography (CT) scan was placed around 8:30
a.m. for an elderly patient with abdominal pain when
previous test results were inconclusive. The patient’s
nurse knew that according to policy, the scan should be
performed that day. When it had not yet been completed
by 5 p.m., the nurse called the CT department and was
informed that the scanner had malfunctioned, resulting
in a backlog. Because the patient was still in pain, and the
nurse knew the physician was waiting for the CT scan, he
attempted to call the CT manager, but she was unavailable.
At 6 p.m., the nurse called his supervisor and explained
the situation. The supervisor called the CT
manager, who was still unavailable, and then called the
director of imaging services. Within 15 minutes, the patient
was undergoing the CT scan, which revealed an obstruction;
the patient was subsequently taken to undergo
surgery. Had the nurse not been persistent in following
up and using the chain of command, the patient’s condition
may have deteriorated. By following the chain of
command, he fulfilled his duty to advocate for the patient
by ensuring that the physician’s order was carried out in
a timely manner and in the process protected himself and
the hospital from possible liability.
Documentation of the steps taken and the communication
that takes place between caregivers is also crucial
to following the chain of command. Medical record documentation
should include patient assessments and observations,
along with the date, time, the names of
individuals contacted, any orders received and carried
out, and other factual information. Along with its importance
in patient care, accurate documentation in the record
can assist in the defense of a liability claim by
providing written evidence of actions taken to meet the
standard of care. As noted in the case summarized in
“Failure to Pursue Physician Bedside Evaluation,” a lack
of documentation contributed to the inability to defend
the case. Documenting non-responsiveness of the physician
or others should be done factually and objectively.
It is important not to use the medical record to attack the
physician or assign blame. Jousting in this way only
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6 Healthcare Risk Control
Sample Chain-of-Command Schematic
The diagram below depicts the flow of communication,
starting with a staff nurse, as chain of command
is invoked.
1. Conflict arises in patient care between staff nurse
and resident.
2. Direct communication by staff nurse with resident
to communicate concern/clarify orders; if unresolved,
go to 3.
3. Notification of attending physician, communication
to resolve conflict; if unresolved, go to 4.
4. Notify nurse manager.
5. Nurse manager communicates with attending
physician to resolve conflict. Attending physician
communicates back to resident and staff nurse; if
unresolved, go to 6.
6. Nurse manager notifies nursing director.
7. Nursing director communicates with chief of
department to resolve conflict.
8. Chief of department communicates with attending
physician. Attending physician communicates
with staff nurse to resolve conflict. If still unresolved,
go to 9.
9. Nursing director notifies administrator
10. Administrator communicates with chief of department
to resolve conflict and takes appropriate final
action in conjunction with chief of department.
Communication flows back to medical and nursing
staff.
reduces the credibility of the record and can lead to finger
pointing in situations that result in a malpractice suit.
Chain of Command in High-Risk
Areas
As noted above, the failure of a nurse or other staff member
to appropriately invoke the chain of command to bring
about necessary interventions places patients at risk for
harm and exposes the caregiver and the organization to liability.
This is especially true in high-risk areas such as obstetrics,
surgery, and the emergency department (ED).
Obstetrics
Obstetrics is especially fraught with failures to escalate
clinical concerns to the next level when urgent patient
care concerns are relayed to the responsible provider but
he or she does not act on them. According to one attorney
and insurance company leader, a majority of the obstetrics
malpractice claims reviewed in one year included allegations
that the hospital either did not have or did not
follow an appropriate chain-of-command policy. 17 Common
areas of liability in obstetrics involve allegations of
fetal injury due to a failure or delay in performing a cesarean
section. The events leading up to fetal injury often
include allegations of failure to intervene or delay in
responding to indications of fetal distress. Frequently,
lawsuits in these cases allege that the obstetrics nurse did
not invoke the chain of command to force the necessary
intervention to address the condition of the fetus.
In one obstetrics case, a jury found the hospital liable for
failing to have a functional chain-of-command policy for
the nursing staff to follow. This verdict was upheld by an
appellate court that said the hospital had a duty to provide
a process for the timely reporting of any situation that creates
a threat to a patient’s health. 18 In Campbell v Pitt County
Memorial Hospital, Inc., a nurse expressed concerns to the
obstetrician about a non-reassuring fetal heart rate pattern
during labor but sought no other recourse when the physician
did not address the problem. The hospital had no
formal chain-of-command policy in place.
In another case, which settled for $4 million, a newborn
suffered severe brain damage allegedly because the
attending physician was negligent in ordering pitocin
and slow in performing a cesarean section delivery.
While the plaintiffs’ experts agreed that some brain injury
may have taken place due to bleeding complications that
occurred before the mother’s arrival at the hospital, they
opined that if the infant had been born sooner, the baby
would have had cognitive functioning.
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Risk and Quality Management Strategies 19 7
Reportedly, the nurse placed the mother on her left
side, administered oxygen, and called the on-call physician
in response to a non-reassuring fetal heart rate pattern,
although the attending physician was on his way to
the hospital. The on-call physician did not communicate
the possibility that a cesarean section may be required,
and thus the hospital took no action to prepare for one.
When the attending physician arrived, he ordered pitocin,
which was later increased despite fetal heart rate tracings
that, according to the plaintiff’s expert, would
indicate that the drug should be stopped. The nurse did
not intervene to question administration of pitocin and
failed to go up the chain of command to stop it when the
fetal heart rate showed late decelerations and lacked beatto-beat
variability. 19
When obstetrical emergencies merit timely medical intervention,
the nurse or other caregiver should act
promptly and not allow the patient’s condition to worsen
before contacting the medical provider. Persistence may
be necessary to overcome obstacles to communication,
and the line of authority should be followed if there is a
lack of response or inappropriate response. 20 Some obstetrics
liability experts recommend that a nurse who telephones
a physician with an urgent problem should not
hang up until the desired response is obtained, including
getting the physician to come in to see the patient. 21 When
a desired response is not obtained, the chain of command
should be used to attain the necessary intervention.
When obstetrical emergencies merit timely medical
intervention, the nurse or other caregiver should
act promptly and not allow the patient’s condition
to worsen before contacting the medical provider.
The concept of the “high-reliability perinatal unit” is
gaining recognition as a strong patient safety and risk
management strategy in obstetrics services. 22 In the highreliability
unit, teamwork and superior interprofessional
communications are the hallmarks of the unit, and physicians
always come in to see the patient when asked. 23
While implementing the principles of a high-reliability
unit does not eliminate the need for clear chain-of-command
policies, the frequency with which such policies would
need to be activated could be reduced. This is because the
obstacles to communication are proactively addressed,
and the orientation of the providers and staff of such units
is always focused on the confirmation of maternal and fetal
well-being. 24 In fact, frequent use of the formal chainof-command
policy instead of open, direct
communication to modify behavior has been identified
as an attribute of a perinatal unit with an unacceptable
amount of adverse outcomes and/or professional liability
claims. 25
Nowhere is the need for unambiguous patient care
and safety policies and clear avenues for
enforcement of those policies more necessary than
in the operating room.
Surgery
Nowhere is the need for unambiguous patient care
and safety policies and clear avenues for enforcement of
those policies more necessary than in the operating room
(OR), where situations that necessitate use of the chain of
command may arise. For example, one of the main recommendations
for limiting the fire risk presented by use
of skin preps in the OR is to allow all flammable preps to
fully dry before draping the patient. 26 Nevertheless, according
to the Association of periOperative Registered
Nurses’ (AORN) 2003 workplace safety member survey,
40% of respondents said that fire risk was a concern. Also,
surgeon impatience was given as a reason for not waiting
for alcohol-based preparation solutions to dry before
draping the patient and starting the procedure. 27 Education
becomes a key risk-reduction activity because physicians
and other surgical staff learn how to recognize
fire-risk situations and avoid them whenever possible.
Another risk-reduction activity is assertion — hospital
staff must be willing and able to speak up when they
know something is wrong. 28 If appropriate interventions
or behaviors do not occur once an unsafe situation is
identified and the responsible individuals are made
aware, the chain of command should be invoked. As the
above example demonstrates, noncompliance with fire
safety procedures places a patient at risk and meets the
conditions for utilizing the chain of command.
However, the case below exemplifies how knowledge
of well-formed patient care policies and confidence in a
clear chain-of-command protocol can actually avert the
need to implement it. 29
After the first closing count of instruments, needles, and
sponges revealed that one piece of polyester tape (used to
tie off the ends of the bowel during colon surgery) was
unaccounted for, the circulating nurse notified the surgeon
that the tape could not be located. Instead of stopping the
wound closure, the surgeon responded by saying that he
did not have the tape and continued to suture the wound.
The circulating nurse conducted a second search but was
unsuccessfulinlocating the tape, and thesurgeonwas again
notified. Insisting that the circulating nurse must have lost
the tape, the surgeon continued to close the wound.
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8 Healthcare Risk Control
Aware of surgical department policies and procedures
on incorrect counts, the circulating nurse knew that the
surgeon should stop and search the wound for the missing
tape. The nurse also knew her responsibility for patient
safety and that she should notify her supervisor
when she could not resolve a situation that jeopardized
a patient’s safety. The nurse insisted that the surgeon stop
the closure and search the wound, making it clear that it
was her duty to call the supervisor if policies were not followed.
The surgeon reopened the wound at that point, located
the missing tape, and removed it. The nurse’s
appropriate actions saved the patient an unnecessary
x-ray and a return to surgery.
Awareness and assertion in carrying out a professional
duty that is rooted in administrative procedures
designed to support patient safety, such as chain of command,
can prevent situations that place patients at further
risk of injury. This in turn averts the need to invoke
the chain of command. A nurse or other staff member
should not use the chain of command as a threat to physicians
or against nonconformist behaviors, but rather as
a valuable resource to be used discriminately and with
the utmost professionalism. 30
Emergency Department
Due to the critical nature of timely decision making in
the ED, where patients may require immediate clinical interventions,
a direct chain of command should be available
to staff. Immediate access to an individual with
clinical decision-making authority (e.g., the medical director)
is ideal.
In one ED case, a registered nurse certified in advanced
cardiac life support (ACLS) questioned an ED physician’s
order for the drug Verapamil for a 46-year-old patient
with ventricular tachycardia (V-tach). However, the
nurse did not further intervene to stop the drug’s administration
even though she knew it presented a high degree
of risk. Within two minutes of receiving Verapamil, the
patient convulsed, went into cardiac arrest, and suffered
permanent brain damage. A lawsuit was subsequently
filed against the hospital, the nurse, and others on behalf
of the patient, who lacked independent motor function
and ability to speak. A jury returned a verdict for the
plaintiffs, which was affirmed by an appeals court. 31 As
this case illustrates, questioning the drug order did not
sufficiently fulfill the nurse’s duty to intervene to prevent
its administration to the patient. By virtue of her emergency
nursing background, experience, and ACLS certification,
the nurse knew that while Verapamil can be
effective in treating supraventricular tachycardia (SVT),
it can be fatal if given for V-tach. In hindsight, the nurse
in this case should have further questioned the physician
and used the chain of command to stop the administration
of Verapamil. 32
Other Care Settings
Ambulatory and home care are examples of other care
settings that require clear chain-of-command policies. Although
patient acuity may be lower, the need remains for
a process to intervene in the event that a patient care conflict
occurs. Because care is provided outside the walls of a structured
facility, a home health nurse or therapist may be especially
vulnerable to situations involving unclear medical
orders or physician unavailability. A straightforward procedure
to act on behalf of the home-based patient can help
avoid harm and improve patient safety.
When care is provided outside the walls of a
structured facility, a home health nurse or
therapist may be especially vulnerable to
situations involving unclear medical orders or
physician unavailability.
A nurse working in a private physician’s office must
also recognize his or her professional duty to the patients
in the practice. In the event that the physician’s actions
endanger patients or that medical treatments are inconsistent
with the standard of care, the office nurse has the
obligation to intervene, first through direct communication
with the provider and then to another, higher authority
— which may ultimately be a state medical board. 33
Implementing a Chain-of-Command
Policy
A written chain-of-command policy should include a
policy statement that succinctly states the policy’s purpose
and for whom it is intended. When lines of authority
are unclear or overlap, specific guidance should be given
on the most direct means of communication making decisions
regarding patient care. This is especially important
in high-risk areas or on patient care units with
multiple clinical providers, such as critical care units, or
on teaching services. The descriptive flow of communication
may vary among departments or patient care units
depending on their structure and organization.
It is important that the medical staff and medical education
program faculty provide input for and/or be apprised
of the nature of the institution’s chain-ofcommand
policies so that they understand and support
application of the policies when resolving patient care
conflicts. In order to evaluate the chain-of-command
policy, use of the policy should trigger an assessment of
its effectiveness. This can be accomplished by applying
©2004 ECRI. May be reproduced by member institution only for distribution within its own facility.

Risk and Quality Management Strategies 19 9
root- cause analysis to the event(s) involving a decision to
employ chain of command. Policies should be reviewed
periodically and revised as necessary to ensure that they
reflect the actual structure and authority of the applicable
departments and units.
Education
Even well-written chain-of-command policies will
have limited usefulness if management, providers, and
staff do not receive adequate training on when and how
to use the policies. Chain of command should be reviewed
with all new medical staff appointees and at new
employee orientation. It should be presented in a
straightforward manner using sample patient care scenarios
and can be incorporated into patient safety education
programs. To strengthen continued understanding
and use of chain of command, annual education on the
topic is suggested.
Communication Techniques
Education for nursing or other staff on chain of command
should include clear guidance on effective communication
skills during emergent situations or when a
patient’s clinical condition prompts timely medical intervention.
The failure to explain the exact reason for contacting
the physician or to convey the urgency of the
situation to the physician may prohibit an appropriate intervention.
Obtaining the desired response or necessary
intervention from the physician can make the need to invoke
the chain of command an infrequent event, improve
patient safety, and reduce exposure to liability.
The following are some techniques for nurses or other
healthcare professionals to use when communicating
with physicians to help convey the need for specific patient
care actions.
• Know which physician to call — attending or surgeon,
for example. This may depend on the nature of the
problem, or protocols might specify that the on-call
resident be contacted first, such as in a teaching facility.
• When placing calls during the night, ensure that the
physician is fully awake before giving critical information
and insist on adequate verbal responses that confirm
that the physician understands there is a high-risk
situation. 34
• Make clear all telephone communication with the physician.
State exactly what action or intervention is being
sought — for example, “The patient is bleeding and you
need to come in now.” Being prepared avoids having to
search for the “right words” or “story” to convince the
physician of the urgent nature of the call. 35
• If the physician responds by asking questions about
assessments, treatments, vital signs or other parameters,
the caregiver should not take it as an attack on competency—thephysicianmayjustbetryingtomore
deeply understand the situation at hand.
• Have all pertinent patient information (e.g., vital
signs, assessments) available, and keep the medical record
close at hand.
• Document exactly what information was relayed to
the physician and when, what orders were received in
response, and when these actions took place.
These techniques can enhance communication skills
and assist the nurse or other healthcare professional in articulating
the cause of concern and what intervention is
being requested.
ACTION RECOMMENDATIONS
• Develop chain-of-command policies or evaluate existing
chain-of-command policies, and ensure that they
reflect current lines of authority for administrative and
clinical decision making. Involve medical staff representatives,
facility managers and leaders so the policies
will be supported in the resolution of patient care
problems or conflicts.
• Assess the safety culture and the staff’s view of teamworkandcommunicationthroughsuchmeansas
safety climate surveys and leadership rounds. If
viewed poorly, it may be necessary to first address an
underlying climate of intimidation, perceived inability
to question the work of others, and lack of interprofessional
collaboration before implementing new or
revised chain-of-command policies.
• Conduct a proactive risk assessment using failure
mode and effects analysis (or a similar process) to
evaluate chain-of-command policies, and use rootcause
analysis or other analytic techniques to ascertain
the causes of chain-of-command failures. Base improvements
in chain-of-command policies on the results
of these assessments and analyses.
• Provide education to physicians and other providers,
managers, nurses and healthcare professionals/technicians,
and other staff on chain-of-command policies.
Include the purposes of the policy and conditions under
which chain of command should be invoked. Use
patient care situations, sentinel events, and liability
claim summaries as examples, and employ roleplaying
methods when possible to simulate scenarios
in which chain of command should be used.
• Review communication techniques, such as those outlined
above, with nursing and other staff members to
promote clear exchanges of information regarding patient
care.
©2004 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2004

10 Healthcare Risk Control
Notes
1. Davis PD. The nurse’s duty to intervene — initiating the chain
of command [online]. 2003 Apr [cited 2004 Jun 1]. Available
from Internet: http://www.thedoctors.com/risk/general/
practiceguidelines/j4242.asp. Citing: O’Keefe ME. Nursing
practice and the law. Philadelphia: F.A. Davis Company;
2001:140-1.
2. American Society for Healthcare Risk Management
(ASHRM). Risk Management Program Development Tool
Kit. Chicago: ASHRM; 2001.
3. Luther KM, Maguire L, Mazabob J, et al. Engaging nurses in
patient safety. Crit Care Nurs Clin North Am 2002 Dec;
14(4):341-6.
4. Ibid.
5. Greenwald LM, Mondor M. Malpractice and the perinatal
nurse. J Perinat Neonat Nurs 2003 Apr-Jun;17(2):104.
6. Ibid.
7. Stein LI. The doctor-nurse game. Arch Gen Psychiatry 1967;
16(6):699-703.
8. Kosnik LK. The new paradigm of crew resource management:
just what is needed to reengage the stalled collaborative
movement? J Comm J Qual Improv 2002 May;28(5):235-41.
9. Longo DR, Young J, Mehr D, et al. Barriers to timely care of
acute infections in nursing homes: a preliminary qualitative
study. J Am Med Dir Assoc 2002 Nov-Dec;3(6):360-5.
10. Simpson KR, Knox GE. Perinatal teamwork: turning rhetoric
into reality. In: Simpson KR and Creehan PA (eds).
AWHONN’s. perinatal nursing (2nd edition) Philadelphia:
Lippincott; 2001:53-67.
11. Kohn LT, Corrigan JM, Donaldson MS (eds.) To err is human:
building a safer health system. Washington (DC): National Academy
Press; 1999:156.
12. ECRI. Improving patient safety: from theory to practice. Risk
Manage Reporter 2003 Oct;22(5):17-8.
13. Institute for Safe Medication Practices. Intimidation: practitioners
speak up about this unresolved problem. ISMP Medication
Saf Alert 2004 Mar 11.
14. ECRI, supra note 12.
15. ECRI. Patient safety rounds — a new tool for reducing medical
errors. Risk Manage Reporter 2003 Dec;22(6):1, 3-7.
16. Morgan DW. Going up the chain of command. RN 2003
Jun;66(6):67-70.
17. Chemieleski S. Obstetrical liability from an underwriting perspective.
Presented at: American Society for Healthcare Risk
Management Annual Conference. 2003 Nov 2-5; Nashville (TN).
18. Campbell v. Pitt County Memorial Hospital, Inc., No. 352 SE 2d
902 (N.C. App. 1987).
19. Breaking News. Multi-million dollar settlement medical
negligence case [online]. [cited 2004 May 21]. Available from
Internet: http://www.jgllaw.com/.
20. Mahlmeister L. The perinatal nurse’s role in obstetric emergencies:
legal issues and practice issues in the era of health care
redesign. J Perinat Neonat Nurs 1996 Dec;10(3):32-46.
21. Garza M, and Piver JS. Many claims involve caregiver communication
breakdowns. OB GYN Malpract Prev 2004 Jan;
11(1):1-6.
22. Knox GE, Simpson KR, Grarite TJ. High reliability perinatal
units: an approach to the prevention of patient injury and
medical malpractice claims. J Healthc Risk Manage 1999
Spring;19(2):24-32.
23. Knox GE. Current issues in obstetrics liability. Presented at:
American Society for Healthcare Risk Management Annual
Conference, 2003 Nov 2-5; Nashville (TN).
24. Ibid.
25. Knox GE, Simpson KR, Townsend KE. High reliability perinatal
units: further observations and a suggested plan for action.
J Healthc Risk Manage 2003 Fall;23(4):17-21.
26. ECRI. Surgical fires: education necessary to address more than
100 fires annually. Risk Manage Reporter 2003 Oct;22(5):1, 3-8.
27. Association of periOperative Registered Nurses. Survey identifies
workplace safety issues of greatest concern. AORN Connections
2004 Jan;2(1):1, 4-5.
28. Groff H, Augello T. From theory to practice: an interview with
Dr. Michael Leonard. Forum 2003 Jul;23(3):12.
29. Denault D. What counts most in the operating room. Nursing
2002 Apr 1;32(4):HN8.
30. Davis PD, supra note 1.
31. Tammelleo AD. Failure to act when you know error on meds
risks life. Regan Rep Nurs Law 2003 Nov;44(6).
32. Ibid.
33. Brooke PS. Questioning the physician. Don’t hold back. Nursing
2002 Dec;32(12):28.
34. Garza M, supra note 21.
35. Simpson KR, Knox GE, supra note 10.
©2004 ECRI. May be reproduced by member institution only for distribution within its own facility.

Risk and Quality Management Strategies 19 11
SAMPLE POLICY
Appendix
Reprinted with permission from Norton Healthcare, Louisville, Kentucky.
All policies, procedures, and forms reprinted in the Healthcare Risk Control (HRC) System are intended not as models,
but rather as samples submitted by HRC member and nonmember institutions for illustration purposes only. ECRI is not responsible
for the content of any reprinted materials. Healthcare laws, standards, and requirements change at a rapid pace,
and thus, the sample policies may not meet current requirements. ECRI urges all HRC members to consult with their legal
counsel regarding the adequacy of policies, procedures, and forms.
2004 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2004