The emergency department physician diagnosed bacterial pneumonia and discharged the child with a prescription for an antibiotic and ibuprofen. The child became unresponsive at home later that same day. His parents took him to a different hospital. At the hospital he began seizing. A CT showed abnormal intracranial signs. He was intubated and given IV fluids.  The child died in the hospital the next day from cerebellar tonsillar herniation due to brain swelling.

  The Court of Appeals of Texas validated the parents’ lawsuit against the first hospital based on a physician’s expert opinion faulting the hospital’s emergency nurses for failing to invoke the institutional chain of command.   Invoking the chain of command is a hospital nurse’s legal duty as the patient’s advocate when the physician makes a treatment decision that threatens the patient’s health or safety.

  How to invoke the chain of command must be defined ahead of time by nursing management and nurses must be instructed what steps a nurse is expected to take. As a rule a staff nurse must go to the charge nurse, the charge nurse to the unit manager, the unit manager to the house supervisor, the house supervisor to the physician in question, then up the physicians’ hierarchy all the way to the top until appropriate action is taken.  Nurses’ failure at any level in the chain to advocate for the patient can expose the institution to liability apart from the physician’s malpractice.