Chain of command: What nurses need to know

Nurses are working in an increasingly complex and stressful environment. At times, a situation may arise that the bedside RN is unable to resolve without further guidance or just-in-time assistance from the leadership team or medical provider, particularly if it involves patient safety. The best way to communicate the need for additional assistance is to initiate the department’s chain of command policy.

A chain of command is an authoritative structure used to resolve administrative, clinical, or other patient (or worker) safety issues using an established process for healthcare workers to present a concern through the lines of authority until a resolution is reached. A formal chain of command provides staff with access to immediate guidance, examples of actions to be taken, and exceptions for documentation.

Most organizations have a chain-of-command policy that guides staff on whom to notify for an unresolved patient safety issue or administrative question.

If your organization does not have a chain of command policy, follow these steps for escalation of the concern/patient safety issue:

If the question or concern is not resolved with a given level of leader, escalate to the next level.

• Notify the charge nurse for assistance.
• Notify the hospital supervisor or the equivalent.
• Notify the manager / director of the unit.
• Notify risk management.
• Notify the administrator on call.
• If it is a physician issue, notify the chief medical officer.

Particularly with current healthcare delivery challenges, RNs continue to have the obligation to escalate concerns and advocate for the patients using available resources and established policy. Ignoring or avoiding concerns may put an RN’s licensure at risk. The good news is that there are resources to contact in the chain of command to work through the patient safety concern for timely resolution.

Take the time to locate and review your organization’s chain-of-command policy so you are prepared when faced with a challenging patient safety concern.

Once the immediate concern is addressed, the RN must consider filing an incident report for occurrences or near misses outside the usual operations of the hospital. Depending on the circumstances, it may be beneficial to notify your nurse representative and complete an Assignment Despite Objection (ADO) for RNs represented by a union.