Chain of Command: Issues in Communication and the Organization of Care


When an adverse outcome and missed diagnosis occur, problems in the organization of care and issues with communication between caregivers are frequently the true cause rather than an isolated error made by one practitioner. In recent years, seeking to capitalize on frustration with the health care delivery, plaintiff’s lawyers have sought to identify disagreements among providers in patient management and/or errors within the patient care management system. Allegations that nonphysician personnel should have recognized a problem with the care plan and accessed the “chain of command” in an effort to alter the clinical course are included in these types of claims.

When an adverse outcome and missed diagnosis occur, problems in the organization of care and issues with communication between caregivers are frequently the true cause rather than an isolated error made by one practitioner. In recent years, seeking to capitalize on frustration with the health care delivery, plaintiff’s lawyers have sought to identify disagreements among providers in patient management and/or errors within the patient care management system. Allegations that nonphysician personnel should have recognized a problem with the care plan and accessed the “chain of command” in an effort to alter the clinical course are included in these types of claims.

Unfortunately, problems of communication are far from simple and are often compounded by failure to engage in critical thinking and the absence of flexibility in considering alternative explanations once an original assessment is reached. As the cases in this column explore, an interactive team wherein communication is encouraged is far more effective than an approach that is egocentric. Ultimately , every care provider needs to be concerned about his/her obligation for patient advocacy. In select instances there may be a need to resort to the command chain. However, even if the chain of command is initiated experience indicates that most often  it will  not prove to be a panacea.

Case: Who’s on First?

Patient A, an obese 22 y/o G3 P0111 woman at 32 weeks’ gestation, presented to the hospital during the afternoon with complaints of lower abdominal pain. She attributed her distress to the recurrence of a urinary tract infection (UTI). Indeed, her medical record included treatments for multiple UTIs, and on one occasion she had experienced pyelonephritis during a prior pregnancy. Upon examination, the physician noted vague lower pelvic and questionable flank tenderness. The fundal height was dates consistent. Occasional but irregular uterine contractions were palpated. 

After a telephone consultation with her OB, a nonstress test was performed and interpreted as acceptably reactive for gestational age. The presentation was unstable breech, the cx long and closed, and the presenting part high. A UTI was diagnosed based on past and recent history and a clean catch urine that was described as “dirty.” Intravenous (IV) hydration and an initial single parenteral dose of a cephalosporin were ordered to be administered prior to her discharge. Because of a change in the nursing shift, there was a delay and IV antibiotics were not started until approximately 30 minutes later. In the interim, however, the patient’s discomfort increased and she had additional complaints of pain. RN #2 called the OB’s office due to the change in the patient’s status. However, because the primary OB was now out of the office and involved with a laboring patient, a different OB took the call. He ordered an increased rate for the IV fluid and “continued observation.” The nurse implemented these orders but then was reassigned to other nursing duties. Consequently, RN #3 began caring for the patient. Shortly after assuming care, approximately 45 minutes after the implementation of the last order, RN #3 assessed the patient and was concerned about her status. She noted an increase in uterine activity with no patient improvement. 

RN #3 called the covering OB again. After discussion with the nurse, he agreed to see the patient at the conclusion of office hours. At the nurse’s urging, a telephone order for hospital admission was made. The admitting diagnosis was “early pyelonephritis.” The physician also ordered the administration of 15 mg of morphine sulfate. Approximately 40 minutes later, a fetal tachycardia of 185 bpm was identified. The patient was observed to be pale and anxious but remained afebrile. Her heart rate was 105 bpm. Uterine activity was more regular and strong. The physician was again contacted by RN #3; he advised her that he would be at the hospital “within the hour.” Unfortunately, 15 minutes later, intermittent fetal bradycardia was observed. The attending physician was now called STAT. The mother was complaining of pain that was both severe and unremitting . No vaginal bleeding was observed however the uterus was tense to palpation. An U/S examination at bedside revealed a large retroplacental hematoma. An emergent cesarean followed, productive of a flaccid and unresponsive 2200 gram female fetus,with APGAR scores Of 2, 4, and 4 at 1, 5, and 10 minutes, respectively. After a stormy course the neonate succumbed 12 days later to complications of prematurity and asphyxia/sepsis.

Subsequently, a lawsuit was filed against OB #2 and his group practice as well as the hospital for its nursing staff. The on-call physician was alleged to have ignored clear evidence of patient deterioration, failed to identify a serious obstetric complication, and inappropriately ordered narcotic sedation prior to reexamination, thus masking important signs and symptoms. Claims against the hospital and its nursing staff included allegations of failures in nursing assessment as well as the failure to initiate the “chain of command” when the physician did not respond in an appropriate manner to telephone calls once the patient’s condition was noted to change.

Next: Case Critique



This case includes a number of egregious diagnostic and management errors arising from problems of serial examination and communication. Among the principal problems were the replacement physician’s acceptance of an initial evaluation made by another practitioner when clinical features of the case were both atypical and undergoing rapid change. The other errors concerned establishing a correct diagnosis.

The initial presumptive diagnosis of a UTI was virtually inevitable. There was a strong history of prior infection, the patient herself believed she was experiencing a recurrence, and the initial urinalysis was interpreted as abnormal. In retrospect, the urinalysis was likely contaminated, probably via the method of collection.  Although the presenting signs and symptoms were supportive of a UTI, the problem arose when the patient’s symptoms increased and yet there was no concomitant consideration of other possibilities. In retrospect, the clinical course was typical for a silent but advancing placental abruption, which progressed to a serious degree before it became clinically recognizable. Flexibility in clinical assessment was needed. The goad to the reevaluation should have been the progressive change in the clinical signs and symptoms.  Changes were perceived by RN #3 but apparently  not clinically significant to OB #2; he either failed to properly credit the nurse’s ability to judge the patient’s deterioration or he failed to consider the significance of her assessment.

The difficulties encountered were exacerbated by multiple caregivers being involved with the patient.  There are inherent risks in when responsibility for care is passed from one physician to the next, from one mid-level provider to another, or from one nurse to another nurse.  Communication lapses are not uncommon at these times. Furthermore, delays in appreciating clinical changes can occur following a transition if report and prior documentation of the patient’s condition is not effective. The converse is also true, it is important that once there has been a reconfiguration of the team, should a new member bring into play a different clinical insight,  there  must be a willingness to be open to those insights.  In this case, the subsequent RN recognized a concern but it was met with resistance from the obstetrician that may well have been critical to the outcome.

In sum, the diagnostic errors include accepting a diagnosis based on incomplete and potentially unreliable data (the contaminated “clean catch” urinalysis) without considering other diagnostic options. The greatest error occurred when the patient developed increasing discomfort and the “half way” measure of a single IV dose of antibiotic was ordered. There is no outpatient management of pyelonephritis in pregnancy. Thus, if the diagnosis was considered to be pyelonephritis, parenteral antibiotics, prompt admission, and close reexamination were required. If the situation with this woman was such that narcotics were needed, reevaluation was mandatory as it could no longer be concluded that this was simply a routine UTI-something else was afoot. Either the woman had developed pyelonephritis, or the initial impression was incorrect and there was another previously occult process at work.

Not much can be said concerning the treatment with morphine. Narcotics do have a role in the treatment of pregnant women with acute pain, but the administration of morphine and similar drugs can also mask helpful signs and symptoms and alter the results of fetal monitoring, as it may well have in this instance. The patient should never have been treated with a potent analgesic without a firm diagnosis. Further,  her clinical situation was changing and the initial diagnosis was never verified. UTIs do not require parenteral narcotics for treatment. Something was clearly wrong. Further, as her condition did not promptly improve with hydration and initial antibiotic therapy but in fact worsened, early ultrasound examination might also have been helpful in establishing the correct diagnosis. This test should have been performed or ordered when she failed to respond promptly to treatment and when increasing uterine activity was noted.

Next: Case 2


Case 2: Cassandra’s Tale: Rogue or Right?

Patient B called her physician with complaints of severe abdominal pain and vomiting at 33 weeks’ gestation. At hospital arrival, the patient’s blood pressure was noted to be “elevated.” The baby's heart rate was “in the 170s.” On physical examination the patient had complaints of severe pain and right-sided tenderness. Her hemoglobin/hematocrit levels and her temperature were normal. Following an abdominal/pelvic examination and basic ultrasonography, an early acute abdomen due to appendicitis was suspected. A surgical consult was called.

The ob nurse subsequently observed  that the fetal baseline heart rate was 170-175 bpm with a deceleration to 150 for about 1 minute. She also recorded that she had some difficulty maintaining a fetal heart rate (FHR) tracing due to maternal movement due to pain.

The nurse informed the physician of her concerns regarding fetal status and that she believed a cesarean was indicated due to the FHR changes combined with the severe maternal signs and symptoms. According to the nurse’s subsequent testimony, she tried multiple times to communicate to the attending that she did not believe the baby was doing well and that intervention for fetal indications was indicated.

Ultimately, it fell out that the nurse and the physician were at loggerheads. She contacted the charge nurse and activated the chain of command, reporting her concerns to her supervisor. Soon after these events, the ob nurse evaluated the patient and was unable to obtain accurate heart rate readings. When the external tracing was at length reestablished, the FHR was recorded as 65-90 bpm. Following an evaluation, the OB believed the FHR readings were unreliable due to the mother’s continuous movement. The nurse, however, believed that she established that the true FHR was 70-90 bpm, although would later agree in subsequent testimony that it was difficult for her to obtain a continuous tracing, leaving an uncertainty as to whether the fetal monitor was recording the fetal or the maternal heart rate.

With a clinical diagnosis of acute appendicitis, surgery was planned. No additional tests were ordered. In the meantime, the nurse had notified her charge nurse of the decreased FHR and other features of the case. The expectation was that the senior, supervising nurse would be contacted. However, the charge nurse failed to make this contact so the bedside nurse appealed directly to the nursing supervisor, informing her that she disagreed with the clinician’s interpretation and believed the baby to be in distress. She requested that her supervisor continue up the chain of command to the head of obstetrics for an emergent review of management. Neither the charge nurse nor the nursing supervisor subsequently voiced this nurse’s concerns to either the attending physician or to a more senior department member.

The mother went to the operating room. When the maternal abdomen was opened via a McBurney's incision, approximately 3.5 liters of blood was aspirated. A prompt surgical exploration via a second incision eventually identified the bleeding site as ruptured uterine varicosities. Direct suturing proved unsuccessful and a cesarean was performed for both adequate exposure and control. The mother survived but the infant was badly damaged: atdelivery, the neonate's heart rate was 80 bpm; the cord pH 6.8. The hospital course was complicated by an intraventricular hemorrhage and other complications of prematurity and asphyxia.

The jury subsequently awarded $19.25 million to the child (this amount was later reduced because it was determined that 20% of his injuries would have occurred even in the absence of negligence). On appeal, a new trial was ordered because of certain rulings that were made pertaining in part to the nurse’s testimony and the original trial judge’s jury instructions. The final outcome of this case remains unreported.

Next: Case Critique



This second case involves the serious error of failing to identify occult intraabdominal hemorrhage.  In retrospect, the attending physician was correct in interpreting the patient’s complaints as suggestive of peritoneal irritation. Unfortunately, no serial laboratory data were obtained, it is not clear how the maternal vital signs were interpreted and the possibility of an intraabdominal catastrophy / hemorrhage was not considered. While spontaneous hemorrhage in previously asymptomatic and normal obstetric patients is a distinctly uncommon entity, it is sufficiently frequent that it should have been considered in the preoperative differential. While spontaneous rupture of uterine varicosities is at best a rara avis, abruption placentae, spontaneous uterine rupture, a leaking splenic artery aneurysm, ruptured spleen or liver, among other possibilities could have resulted in a similar clinical picture and abnormal fetal monitoring findings. Certainly, the picture of a patient with abdominal distress and thrashing is inconsistent with peritonitis, as typically the absence of movement is what the patient seeks. As the abdomen was acute, the fetal tracing apparently distinctly abnormal and the mother getting worse, action was required. As always in this and similar cases, the fetal morbidity was related to the delay in both diagnosis and treatment.

The exploration via a small McBurney incision is puzzling. The appendix is displaced upward and laterally in pregnancy and this incision would have been too low if the appendix was actually the culprit. Alternatively, if the diagnosis had been incorrect (as it proved to be) an exploration with a second incision with its inherent delay would have been required. Faced with an acute abdomen of uncertain etiology in a pregnant woman, a midline incision would have been best, even with the problem of exposure represented by the gravid uterus. At least the initial incision could have been extended, if needed, and the uterus deviated laterally as required by the demands of surgery.

As in the first case, the physician’s unwillingness to reconsider his clinical judgment may have been an obstacle to reaching the appropriate diagnosis.  Even if the rarity of the condition and unusual presentation made sorting out the diagnosis difficult, bridging the disconnect with the nurse was still important. It is not uncommon for nurses to be named in lawsuits beside the obstetrician for failing to pursue “chain of command.” It is true that often these claims are unsuccessful because it cannot be established that the decision-making would have been different had the command chain been followed and others summoned for evaluation. However, as this second case illustrates, “chain of command” lawsuits often seek to exploit the joint responsibility for the care and the safety of the patient. In so doing, the underlying motivation for the claim may be to identify any dissention among the providers as rarely can a house divided among itself stand before a jury.

Consequently, it is no surprise that this case resulted in litigation and an unfavorable jury verdict. The complaint named the treating OB, the surgeon, and both the charge nurse and the nursing supervisor. Poor collaboration, either on the part of one or more of the team members-whether it’s the obstetrician, the nurse-midwife, or the nurse-has the potential for conflict. In this case the failure to undertake efforts to resolve the conflict was both potentially devastating to the patient care and was seriously exposed during subsequent litigation. Even if the nurse was being an alarmist (despite the fact that she turned out to be right), consideration of her concerns and inclusion of her concerns in the overall assessment needed to occur for purposes of good team building. Instead, at trial, the RN’s notes, actions, and ultimately testimony became a significant and problematic issue in the defense of the case. Her testimony pertaining to her interpretation of the fetal heart strips and her assessment that intervention was necessary provided independent credibility to the plaintiff’s own experts.  Furthermore, the plaintiff could hold her out as the sole beacon in the night. Ordinarily, nurses are not qualified to present expert testimony on  whether operative intervention is needed in response to FHM findings. However, at trial the nurse’s testimony pertaining to the need for intervention was considered relevant to the failure of the other nursing personnel to access the chain of command. In the end, these chain of command claims were dismissed because there was no evidence that had the nurses followed the chain of command the baby would have been delivered earlier. However, the damage had been done. The nurse’s testimony that she thought a cesarean was needed and her description that she had tears in her eyes while watching the baby's heart rate decrease was both highly emotional and was noted to be a turning point in the case. In fact, the trial judge, whose rulings became the subject of the appeal after the jury found in favor of the plaintiffs, acknowledged on the record that the OB should “start digging [his] grave, because [the nurse’s testimony] is going to kill [you].”

What do we do about chain of command issues? Every member of the team must recognize and respect the obligation that exists for every other team member, with the common thread being the best interest of the patient. In respecting the role of the RN nursing staff, physicians and CNMs must understand that although legally the physician is solely responsible for the diagnosis and treatment of his patient, nurses can breach the standard of care by not adequately advocating for his/her patient’s interests. In respecting the role of the physician, the nursing staff must recognize the complexities of clinical decision-making that is the responsibility of the physician and also be sure not to let personal bias about a physician prejudice their participation in the team approach.

Communication across the nursing–physician barrier can be problematic, especially when strong personalities hold firm views. It is all too easy for nurse queries to be interpreted as interruptions, especially by physicians during times when the practitioner is busy with other important responsibilities. Yet, fostering a team approach to diagnosis in which the nurse/birth attendant is comfortable or permitted to raise questions concerning patient status changes and the concomitant willingness of clinicians to heed these queries is far more efficient because of improved patient outcomes and more efficient team work. Concerns that remain either (a) unvoiced or (b) unresolved undermine confidence and may have significant implications in patient care. When the team is not cohesive, the risk for an unfortunate outcome increases. ,Over time, and in retrospect, it is all too easy for these disagreements to harden into certainties and lead to difficulties in defending care should a negligence case be instituted.

Next: "United We Stand . . ."


“United We Stand…”

Physicians that come to the table with flexibility in whatever preconceived notions of care and without any distractions caused by self-interested motivations will enter the process with a better decision-making mindset and be better engaged in the process of eliciting information or deciding a course of action. These relationships need to be dynamic, particularly since the clinical circumstances are dynamic and teams become reconfigured throughout care. When a provider (CNM, physician) has made management decisions concerning a pregnant patient, all team members share a legal responsibility for her care. No clinician, regardless of how well meaning, can remain in continuous attendance.

There is always a team.

The first case is a reminder that nonspecific signs and symptoms often lead to a differential diagnosis. Atypical presentations of various obstetric complications are frequent and clinical diagnosis is not an exact science. Thus, in many instances only serial study can reveal the true state of affairs. Our ability to train mutually supportive teams remains the best response to such problems, instilling a willingness to consider new opinions in difficult or rapidly changing clinical circumstances. Taking the opportunity to review bad outcomes and even “near misses” is important to identify issues and improve on communication breakdowns, and reduce the risk of  bad outcomes. Finally, while chain of command cases can be difficult for plaintiffs to pursue successfully, disagreements over assessments, evidence of poor responses by clinicians in changing circumstances, and bad feeling between clinicians can become exposed by these claims The clinician’s confusion, inattention, or inflexibility may thus become evident during the litigation process potentially leading to insurmountable hurdles in legal defense.



1.Kowalski v. Palav, A-5348-07T3 (2010).

Disclaimer: The information presented in this article is for informational purposes only and is not to be construed as medical or legal advice.

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