HCM 3080 Module 5 Chain of Command Discussion Example

Module 5 Discussion: Initial Post and Replies

Charting the Warning Is Not Enough: The Nurse's Duty to Go Up the Chain of Command

This week's material on physicians, nurses and medical staff made me think about a pattern I have seen described in incident reviews: a nurse notices a patient getting worse, calls the physician, gets no useful response, documents it carefully, and waits. The documentation is accurate, and the patient still comes to harm. The law has been clear for decades that charting the warning is not the end of the nurse's duty.

In Utter v. United Hospital Center (1977), a patient's fractured arm was placed in a cast, and over the following days nurses recorded swelling, a foul odor, dark discoloration and confusion. The attending physician did not act, and the nurses did not take the concern further, although the hospital's own nursing manual told them to call the department chair if a physician failed to respond. The arm had to be amputated. The West Virginia Supreme Court of Appeals upheld the verdict against the hospital, reasoning that the nurses had a duty to follow the chain of command when they knew the patient was in danger.

State practice law supports the same expectation. New Jersey's nursing statute describes the registered nurse's work as identifying and responding to how people react to actual or potential health problems, through finding cases, teaching, counseling and care that sustains or restores well-being (N.J. Stat. Ann. § 45:11-23). A nurse who recognizes a dangerous change is exercising that professional judgment, and stopping at a phone call that went nowhere is not consistent with it. For administrators, the lesson is that the policy matters only if nurses know it, believe they will be backed up, and have a clear path at 3 a.m., such as a house supervisor or a rapid response team that can be called without the physician's permission.

Reply to Brianna

Brianna, you mentioned that nurses at your hospital worry about being seen as difficult if they go over a physician's head. That concern is common, and research backs you up. Okuyama et al. (2014) reviewed 26 studies on speaking up and found that whether clinicians speak up depends partly on perceived risk to the patient and how clear the situation is, but also on leaders' attitudes, team relationships, administrative support and fear of others' responses. A policy alone does not remove that fear. Do you think a hospital could change it by publicly recognizing nurses who escalated appropriately, even when the concern turned out to be minor?

Reply to Jordan

Jordan, I agree that a written chain of command protects the hospital, but I would push your point further. In Utter, the hospital had a written policy, and the court used it as evidence of the standard the nurses failed to meet. A policy that staff do not follow can increase an organization's exposure rather than reduce it. That suggests administrators should audit whether escalation actually happens, for example by reviewing rapid response calls and cases where deterioration was documented without escalation.

References

N.J. Stat. Ann. § 45:11-23 (2024). Definitions. https://law.justia.com/codes/new-jersey/title-45/section-45-11-23/

Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Services Research, 14, Article 61. https://doi.org/10.1186/1472-6963-14-61

Utter v. United Hospital Center, Inc., 160 W. Va. 703, 236 S.E.2d 213 (1977).