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Chain of Command


We’ve all had the experience where we are dealing with someone who can’t help us, so we go up the line to the supervisor, and maybe even that supervisor’s supervisor. Most jobs have a hierarchy, with the higher jobs being people with more knowledge and/or more authority.

It’s the same with obstetrical nurses and doctors. A problem we often see in birth injury lawsuits is that a “low-level” nurse sees something wrong, and reports it, usually to the obstetrician. The obstetrician will not do enough to address the problem, and the baby is born injured. This often happens when a nurse sees signs of fetal distress that are significant enough to warrant an emergency cesarean section, but the doctor insists on continuing with labor and a vaginal delivery.

The American Nurses Association (ANA) has guidelines which state:

As an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interest of the patient in jeopardy.

Using the chain of command theory, the nurse who reports the problem to the doctor had an additional duty to go over the doctor’s head and find someone else to fix the underlying problem. The nurses should have established procedures setting out the tiers of authority for making decisions. Of course, doctors usually have the final say. However, an obstetrical nurse can often (and should, when necessary) report her concerns to the charge nurse (sometimes called a head nurse), who may then report the situation to the director of the nursing staff. Those “higher-up” nurses may then convince the doctor to take action, or can even themselves consult with other doctors in the hospital.

The specific procedure for instituting the chain of command will vary with the hospital, and may even be documented in hospital manuals. Smaller, more rural hospitals likely will have a less complicated chain of command, while there may be more options (and more requirements) in larger hospital settings. In the final analysis, it is not sufficient for a nurse to rely on the “just following orders” defense. They have an obligation to their patients, and an obligation to prevent harm where possible.

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Obstetrical nurses are the first line of care in any labor and delivery. They are the ones who are present most of the time—the obstetrician will sometimes call in or check in with a visit, but the nurses have the most immediate knowledge of the baby’s condition. When they think something is wrong, the doctors should take it seriously. If the doctor makes the wrong decision, the nurse may have a responsibility to get to a better decision. For more information on the chain of command, contact our medical malpractice attorneys at (440) 252-4399 or online for a free consultation.

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