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Nursing News July 26, 2013

The Chain of Command Protects Your Patients and You

A healthcare organization can be sued for negligence when nurses fail to question an inappropriate order. An attending directed a resident to order 5FC (flucytosine) for a 5-day-old infant who had a yeast infection. The resident mistakenly ordered the chemotherapeutic agent 5FU. Nurses on two shifts observed the 5 rights (but not the right indication) and administered 5FU. A new nurse on the night shift called the pharmacy to question the order and also called the resident who insisted that the attending said to order that medication and demanded that the nurse give it. She gave 5FU and the next morning the infant died (Smalls, 2009).

Any of these nurses could have prevented this death and its legal ramifications had any one of them pursued the chain of command.

“Nurses act with moral courage when they use the chain of command to share and discuss issues that have escalated beyond the problem-solving ability and/or scope of those immediately involved. Engaging the chain of command both ensures that the appropriate leaders know what is occurring and allows for initiating communication at the level closest to the event, moving the discussion upward as the situation warrants” (LaSala & Bjarnason, 2010).

The ANA Code of Ethics and the law hold nurses accountable for their own acts and to the same standard as any nurse with the same training and experience. Nurses with specialized training or extensive experience are held to a higher standard. If a nurse fails to use that knowledge, care, skill, or diligence and the patient is harmed as a result, the nurse can be held liable (Smalls, 2009). To practice competently, a nurse must know or know how to quickly access critical assessment parameters and medication information.

Healthcare organizations develop policies and procedures (P&P) to specify whom to contact first and next when a situation arises that requires intervention beyond the scope of the nurse’s practice. Policies may also state specific acceptable response times. Examples of situations (Banner, 2010) include:

  • The provider has not responded to a deteriorating patient's condition.
  • The nurse questions or disagrees with a provider’s order, plan, or care.
  • The nurse believes the provider’s response to a situation does not fully address the issues.
  • The nurse’s assessment differs from the provider’s assessment.
  • Unprofessional behavior jeopardizes patient care.
  • The nurse suspects that the provider or another team member is impaired.
  • A patient’s end-of-life wishes differ from the opinions of the family and the provider (LaSala & Bjarnason, 2010).
  • The nurse believes that a patient's discharge is premature.

Most situations resolve at the charge nurse level (Cox in ED Nursing, 2010). If time permits, collaborating with others such as a pharmacist (Ridgley in ED Nursing, 2010) or nurse colleagues (Banner, 2010) may help to clarify a situation and information to communicate with the chain of command.

Precise, careful documentation protects the nurse and the organization without accusing another of negligence. For example, “4:00 p.m. 5FU ordered, 4:15 p.m. Dr. Resident called and order for 5FU discussed and clarified times two.” On the MAR, the nurse could have indicated that she did not give the medication and noted: “4:30 p.m. Dr. Attending called. 4:35 p.m. Charge nurse at the bedside” (Smalls, 2009).

Essential Actions:

  • Before you need to use it, access your organization’s chain of command P&P.
  • If the P&P does not specifically address documentation, consult with your Nurse Manager for direction.
  • Before you need to access the chain of command, think through situations that might arise in your unit. Determine who you would contact, what you would say, what you would do if the immediate next contact could not resolve the issue, or if all except you are in agreement with a particular course of action.
  • Know the critical assessment parameters for your patient population.
  • Know the indications, adverse effects, and toxic effects of every medication you administer.

Use the chain of command to advocate for your patients and protect yourself from liability.

Bette Case Di Leonardi has worked in nursing, education and healthcare administration for more than 40 years and was among the first group of nurses certified in Nursing Professional Development. Today, Di Leonardi is an independent consultant who publishes and presents on a variety of professional and educational topics.


Banner Health Sterling Regional Medical Center. (2010). Policy and Procedure. Chain of Command for Patient Care Issues.
ED Nursing. (2010). You need to follow chain of command. ED Nursing, 32-33. Quoting T. Cox and E. Ridgely.
LaSala, C.A., Bjarnason, D. (2010) "Creating workplace environments that support moral Courage" OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 4.
Smalls, H.T. (2009). Nursing liability and chain of command. Neonatal Network, 28(6), 401 – 402.