Avoiding Liability Bulletin – January 15, 2017

There is no doubt that whether you are a nursing student, a novice nurse or a seasoned practitioner, you have heard of the chain of command in nursing practice.  Although the definition of chain of command may vary slightly, generally speaking it is “the order in which authority and power in an organization is wielded and delegated from top management to every employee at every level of the organization.  Instructions flow downward along the chain and accountability flows upward”.1

Nursing’s chain of command may vary slightly from institution to institution, but the “organizational chart” of the chain for nursing staff often starts with the charge nurse, then the unit manager, and so forth, with the CNO being the last person in the nursing hierarchy.  The nursing chain also includes the physician and he/she has a chain of command as well.  Often the CNO and the CMO are needed to resolve a patient care issue that involves both nursing and physicians.

The chain of command is extremely important when providing nursing care, especially if when patient care is compromised in some way, as the ED nurses discovered in the following case.2

A mother brought her six- year-old son to the ED with a fever, vomiting, diarrhea, coughing, congestion and a sore throat.3

The young boy was assessed by various ED nurses and an ED physician.  In addition to the reported symptoms, his resting heart rate and breathing were abnormally fast.  His temperature reading was 99.1. The mother told the nurses that he told her he had a headache while in the ED.  She shared this with the nurses but no further tests were ordered.

Other tests and assessments done indicated that the boy’s throat was red, lab tests indicated an elevated white blood cell count.  In addition, a chest X-ray showed opacification in both lungs.4

The ED physician’s diagnosis was bacterial pneumonia and discharged the boy.  He wrote prescriptions for an antibiotic and suggested Ibuprofen be administered for the headache.

The boy’s condition worsened after he arrived home.  The parents took him to another ED where the boy started seizing.  A CT scan indicated abnormal intracranial signs.  He was admitted, intubated and given IV fluids. The youngster died the next day in the hospital from “cerebellar tonsillar herniation” due to brain swelling.5

The family filed a wrongful death action against the first Hospital’s ED and the ED physician. The family had a physician expert review the chart and his opinion was given to the hospital.  The hospital moved to dismiss the suit, alleging that the physician expert was not qualified to give an opinion on the ED nurses standard of care and that the report was conclusory with regard to the standard of care, breach of that standard, and causation.

The trial court denied the motion and the hospital appealed that decision. The Court of Appeals affirmed the decision and discussed its decision in detail.

The Appellate Court opined that the physician expert was qualified to provide his opinion about the care the decreased boy received.  Not only was he currently practicing in an ED, he was familiar, and had treated, patients with the same condition as the patient. He stated that he had regular contact with ED nurses in his capacity as an ED physician and they had also cared for patients with this same condition.

As to the allegations that the report was conclusory, the Court held that “looking at the four corners of the report, we conclude that the report adequately states the standard of care applicable to emergency room nurses”.6

Furthermore, the Court, relying on the physician expert report, clearly admonished the ED nurses for not invoking the chain of command and obtain an order preventing the child from being discharged.  The report clearly stated that the ED nurses’ standard of care was to recognize the child’s condition had worsened and, despite the ED physician’s not admitting the child, had an obligation to utilize the chain of command to prevent the child from being discharged.  Had the child been admitted, he would have received “supportive therapies and treatment” which may have prevented his death.

The principles that you, as a nurse, need to adhere to, whether practicing in the ED or elsewhere, are:

  1. Keep clinically current in your area of practice;
  2. Don’t remain silent when a patient’s condition worsens;
  3. Be certain your institution has a chain of command policy and, if not, talk with your CNO about the need to develop and implement one as soon as possible;
  4. Know and follow your institution’s chain of command step-by-step; and
  5. Document accurately and completely your attempts when using your institution’s chain of command.


  1. “Chain of Command” (n.d.)@ businessdirectory.com/definitions/chain-of-command.
  2. Christus Spohn Health Systems Corporation v. Hinojosa, No. 04-16-00288-CV, 4th Circuit Court of Appeals (San Antonio, TX), December 21, 2016.
  3. , at 2.
  4. “Emergency Department: Court Faults Nurses, Did Not Invoke The Chain Of Command” ( January 2017), 25(1) Legal Eagle Eye Newsletter For the Nursing Profession,
  5. Hinojosa,supra note 2, at 10.


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About the Author

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Nancy Brent

NANCY J. BRENT, MS, JD, RN, received her Juris Doctor Degree from Loyola University Chicago School of Law. Ms. Brent has been in practice for over 40 years and concentrates her solo law practice in education and consultation for nurses, nursing organizations, and health care delivery systems. She also defends nurses before the Illinois Department of Financial and Professional Regulation. Ms. Brent has published and lectured extensively in the area of law and nursing practice.