01.05 Documenting Escalation (Chain of Command)

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Included In This Lesson



  1. Chain of command

    1. Line of authority

    2. Steps taken by nurse

      1. When issue arises

      2. Without immediate resolve

        1. See examples below

    3. Every organization should have one

      1. Policy and procedure

        1. Important to know this!

        2. Protects

          1. Patient

          2. Nurse

      2. Patient advocacy

        1. Clinical judgment

        2. Organization


Hey guys, today I have a really important lesson for you all. I want to take a little bit of time to talk about what a chain of command is and why it is important to us as nurses. So what do we mean by the chain of command? So guys, this is basically a line of authority or the steps that we can take as nurses if there would be an issue that needs to be taken to a higher level. Obviously we encounter things everyday as nurses that maybe need questioned and what do we do? We get the issue resolved by speaking with the provider or getting clarification on an order, for example. And then we go on our way. So every organization should most definitely have a policy and procedure regarding the chain of command or the steps that you would take in the instance that there isn’t an immediate resolve with something that you are concerned about. 

This is awesome for the patient, for the nurse and for the organization as it provides protection in a way that we as educated and professional nurses use our clinical judgment and also patient advocacy. So I wanted to give you a few examples of when to escalate the chain of command. Definitely in the instance where you have a deteriorating patient and you’re getting no response from the provider for whatever reason. Of course, you’re not going to just allow the patient to fail. You’re going to follow the chain of command to protect your patients. Another instance would be when you are questioning an order or care. Now guys, of course you’re going to speak with the provider first. Remember you are the patient advocate, so it is your duty. If an order, whether it be a medication that the patient is allergic to or a dose that is too high for a pediatric patient to contact the provider, nine times out of 10 the provider will be so appreciative of the fact that you brought this attention, this issue to their attention and you also are going to gain their respect and trust. 

So do not ever be afraid to use your knowledge as a professional. The issue occurs when you know a harmful order or harmful care is being given and the provider just doesn’t care. A few other examples of the need to escalate include unprofessional behavior by the provider or any healthcare provider. If the provider is impaired or even there is some suspected impairment, that’s definitely a reason to escalate the chain of command or even if you and the provider are not seeing eye to eye on the discharge of a patient. Okay guys, let’s take a look at the steps that you may take. Now, keep in mind that each organization’s policy may differ on the steps, so this is just an example of what your chain of command may look like. So as a stor staff nurse, the first person you would contact is the charge or head nurse of your department. 

Luckily, most issues are resolved at this level, but if the issue isn’t resolved by the charge nurse, you would move to step two which would be the director of nursing. If your issue isn’t resolved here, you had moved to step three, the chief nursing officer or CNO, and hopefully this would be your last step. But if necessary, you might have to move to the medical director or the CEO or hospital administrator. So what do we document in these uncomfortable situations? As a nurse it is very simple for you. All you have to do is document each step taken and simply what exactly you did do not focus on what was not done or what the provider did not do. Finally, guys, it is important that you fill out an incident reports where in great detail you can describe the incident incident reports are so important to organizations as they can provide data for certain trends that are happening at your facility or even help with determining the root cause analysis of issues and remember they are not part of the legal permanent patient’s chart. 

Okay guys, let’s do a quick review. The chain of command is a line of authority and steps taken by the nurse when an issue arises. Organizations have policy and procedures regarding the chain of command to protect, provides protection to the patient and also to the nurse in the organization. Escalation occurs when there is questionable care and impaired provider, unprofessional behavior or even a premature discharge. An example of a chain of command could include contacting the charge nurse first. Then the director of nursing CNL and finally the medical director, CEO or hospital administrator. It is important to document each step, taken all calls that were made, do not focus on what the provider did not do, and finally be sure to complete an incident report, a few nursing concepts that we can apply to this lesson, our communication, health policy and clinical judgment as they are all directly related to the chain of command and policy and procedure. Okay guys, that is it for this lesson on escalation of the chain of command. We love you guys. Go out and be your best self today and as always, happy nursing.