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August • 10 • 2023

The Chain of Command: A Powerful Patient Safety Tool


By Marlene Icenhower, BSN, JD, CPHRM 



Chain of command is a formal, structured communication technique used to resolve patient safety issues. Through this technique, care team members escalate a concern through leadership levels until a resolution is reached.

Chain of command is a formal, structured communication technique used to resolve patient safety issues. Through this technique, care team members escalate a concern through leadership levels until a resolution is reached. The chain of command process provides clear guidance to staff and enhances an organization’s culture of safety.

Case Summary

A 70-year-old man was admitted to a medical/surgical unit following an uncomplicated total hip arthroplasty. Over the next several days, the patient gradually developed shortness of breath, a distended abdomen, and constipation. X-rays revealed dilated loops of bowel indicative of an obstruction or ileus. By day four, the patient was hypotensive and oliguric; to the nursing staff, he appeared to be in acute distress. At this point, his physician examined him, ordered lab tests and rehydration, then returned to his office in the same hospital building.

An hour after the examination, the patient’s nurse attempted to report his critical lab results and worsening condition, but neither the clinic nor the physician answered her calls. Urgent messages left at multiple locations were not returned. As the patient continued to deteriorate, the nurse voiced her concerns to the charge nurse, who attempted to reach the physician herself. When he failed to respond, the charge nurse took no further action.

Several hours later, the patient suffered respiratory arrest. Resuscitation was unsuccessful. The autopsy report listed his cause of death as gram negative sepsis due to ischemic intestinal injury with obstruction and regurgitation of bowel contents.

In the resulting lawsuit, the family alleged that the nursing staff was negligent in failing to aggressively summon medical attention for the patient as his condition was deteriorating.
Typical situations in which the chain of command is invoked include a lack of orders, a nonresponsive practitioner, or a disagreement over patient care. Process elements may vary by organization. Typically, however, the process begins with communication to an immediate supervisor, communication that may extend up the hierarchy to organizational leaders, medical executives, or even governing body members.
While the chain of command is an effective conflict resolution strategy, there may be cultural and organizational barriers to its use. If staff fear repercussions, such as intimidation, disruptive behavior, or retaliation, they may be reluctant to engage in the process. Similar reluctance can emerge if, based on experience, staff perceives the process to be futile or ineffective.

Risk Recommendations

When appropriately utilized, the chain of command can be an effective tool for an organization to enhance patient safety, build trust, support its culture of safety, and prevent similar situations by building awareness. Consider the following when implementing or reviewing your organization’s chain of command policy:
  • Develop a well-defined policy. A written chain of command policy should provide specific guidance to staff during stressful situations. Accordingly, the policy should be clearly delineated and should address key elements such as:
    • Specific steps that are to be used. Include in the chain of command policy and procedure a clear description of the specific process that is to be used. Identify the persons that are to be included in the chain of command process by their job titles rather than names. Include expectations for response times in the policy.
    • When to invoke the process. Typical trigger situations include questioning of orders, a nonresponsive or disruptive practitioner, or a practitioner who does not follow established policies and procedures. Include a decision-making algorithm.
    • Who can invoke the process. Invite any staff member with a safety concern to invoke the chain of command process, regardless of job title.
    • Documentation expectations. Outline expectations for medical record documentation when invoking the chain of command process. Address when to document process invocation in the organization’s incident/event reporting system. 
  • Eliminate cultural and organizational barriers. No matter how well-crafted the chain of command policy, practitioners and staff who fear retaliation and reputational harm or perceive futility will be reluctant to invoke the process. Ensure that the work environment is a safe place where staff feel empowered to question others for the benefit of patient safety. Support psychological safety by ensuring that staff understand that questioning others’ behaviors or decisions is not a sign of weakness or lack of knowledge.
  • Educate all staff. Reinforce how important the chain of command process is in advocating for patient safety, resolving difficult situations, and reducing liability. Identify perceived barriers to the chain of command process, such as fear of intimidation and retaliation, doubt in one’s own abilities, and concern about confidentiality. Coach staff on strategies to overcome these barriers. Provide chain of command process training during new employee orientation and reinforce training at regular intervals.
  • Utilize structured communication techniques. Structured communication techniques can decrease misconceptions and misunderstanding between health team members. Use standardized, structured communication techniques when communicating critical information regarding a patient’s clinical status. Standardized critical communication formats include:
    • Situation, Background, Assessment, Recommendation (SBAR).
    • CUS statement. This is an assertive escalation statement defined as “I am concerned. I am uncomfortable. This is a safety issue. Stop the line.”
  • Evaluate effectiveness. Staff must perceive the chain of command process to be effective to rely upon it as a means of resolving safety concerns. Conduct regular audits to determine whether staff follow policies and procedures when invoking the chain of command process. More importantly, determine whether the process resolves concerns in a timely fashion.
When patient safety is in jeopardy, failure to speak up can result in liability and patient harm. When used appropriately, the chain of command process is a powerful patient safety tool in an organization that embraces Just Culture principles and a patient safety philosophy. 

Additional Resource:
ECRI, Chain of Command. (subscription required)

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances. 


  • Risk Management & Patient Safety