The Nurse’s Duty to Intervene––Initiating the Chain of Command – Hospital Malpractice Lawyer Nathan Hughey
Nathan Hughey
Charleston Injury Lawyer
The following is a great article discussing #surgicalmalpractice, #hospitalmalpractice, #malpracticelaw, #nursingduties, and #nurseadvocates for patients. When a doctor messes up, a nurse has a duty to step up. As a Charleston malpractice lawyer, Nathan Hughey handles claims arising from surgical malpractice and physician negligence when the question of a nurse’s duty arises.
When it comes to medical care and decision-making, do nurses still believe that the physician is in 
charge and that the physician’s word is law?
By Patricia Davis, RN
Perhaps not on an intellectual level, but on a practical level, some malpractice cases reflect significant concerns in this sensitive area.
Nurses have a duty to advocate for the patient through the organizational chain of command1 when they believe that the physician is unresponsive to concerns about the patient’s condition or is making inappropriate patient care decisions. This statement merely confirms the obvious for many nurses. For others, however, this assertion may be somewhat unfamiliar—or even unrealistic.
What Is the Chain of Command?
The chain of command concept should be familiar to all nurses who provide patient care in any setting. The chain of command is a specific course of action involving administrative and clinical lines of author- ity established to ensure effective conflict resolution in patient care situations and is mostly applicable
in emergency situations.2
It is crucial that nurses and physicians have a clear understanding of the established philosophy and procedure and that the policy is implemented and followed appropriately. The absence of an established policy does not, however, lessen the nurse’s responsibility to recognize problems with patient care and take appropriate action to prevent patient injury.
Why Is It Important?
Courts have held that nurses have a duty to question a physician’s order if it is not consistent with standard medical practice. This could be interpreted to mean that nurses must know when a physician’s action or inaction jeopardizes a patient’s safety and well-being.3 This places a significant responsibility on the nurse.
Issues arise when the nurse becomes concerned about the patient’s well-being and the physician is unresponsive or insufficiently responsive. The physician might not return a page, tells the nurse not
to call again about the same problem, or informs the nurse he or she will come in later. These responses convey a lack of concern for the patient and indicate lack of respect for the nurse’s judgment. Examples of clinical situations include:
The dose of a medication is excessive or inadequate.
IV fluid orders are incomplete or inconsistent. The nurse is concerned about fetal heart rate monitoring in a patient in labor.
The postoperative laparoscopic cholecystectomy patient begins having symptoms of an acute abdominal process.
The patient has widely divergent intake versus urinary output.
The patient is allergic to the medication the physician orders.
The nurse must have a high degree of knowledge and wisdom, as well as discernment, in weighing the needs of the patient against the potential consequences of initiating the chain of command.
It is not a method for exercising a personal agenda or settling a grudge against a physician. In order for this procedure to remain a valuable resource, it must be utilized with the utmost care and discretion. To do otherwise calls the professionalism of the nurse into question and jeopardizes his or her reputation.
Documenting This Process
In the unfortunate instance when physician actions are not appropriate and the chain of command is invoked, the nurse must document the events as they occur. Important principles include:
• Record events and observations in the patient’s medical record in an objective and clear manner. • Document the specific facts, and carefully record the time of each entry as accurately as possible. • Avoid fingerpointing and personal attacks on the physician.
Summary
The nurse caring for patients in a health care setting has a responsibility to be an advocate for the patient. While not bearing responsibility for making medical decisions and judgments, the nurse bears significant accountability for intervening when it appears that decisions and judgments are not consistent with the standard of care. An effective communication policy that is well known by all nursing staff and physicians can, by its very existence, improve the quality of care delivered to patients, thereby improving patient outcomes.
Effectively documenting patient care issues as they arise is crucial. Not only is it important to record the events as they occur, it is vital to document the efforts made by nursing staff and others to resolve issues as they arise.
Finally, the ideal outcome is for the nurse and physician to reach an understanding through open and professional communication so that the patient receives optimal, effective care, with safe and successful outcomes—and without a need to formally initiate the chain of command.