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Difficulty: MediumInterprofessional Teamwork and Conflict Resolution

A telemetry nurse is caring for a patient who has developed new-onset altered mental status and hypoxia. The covering resident is paged and orders a high dose of an intravenous opioid analgesic. The nurse recognizes that this medication is strongly contraindicated and likely to precipitate respiratory failure in this patient. The nurse raises this issue, but the resident dismisses the concern and insists the medication be administered immediately. Arrange the following steps in the correct sequential order that the nurse should take to escalate and resolve this patient safety concern according to standard conflict resolution protocols.

  1. 1Reassert the clinical concern to the resident using explicit safety language (e.g., CUS framework).
  2. 2Escalate the situation to the unit charge nurse for immediate nursing leadership support.
  3. 3Contact the attending physician of record to intervene and provide definitive medical decision-making.
  4. 4Notify the hospital administrator on call or chief medical officer.

Answer

The correct sequence is to first reassert the concern to the resident using explicit safety language, then escalate to the charge nurse, followed by the attending physician, and finally the hospital administrator on call if necessary.
The standard protocol for escalating a patient safety concern begins with the Two-Challenge Rule. If the initial concern is dismissed, the provider must reassert the concern using explicit safety language (e.g., CUS: Concerned, Uncomfortable, Safety). If this second challenge is ignored, the provider must 'stop the line' and activate the chain of command. For a nurse, this means escalating to their immediate nursing supervisor (charge nurse). If the charge nurse and resident cannot resolve the issue, it is escalated to the attending physician. If the attending physician is unavailable or the safety threat remains unresolved, the final step is contacting the hospital administrator on call or chief medical officer.

Step-by-Step Solution

1
Identify the immediate failure of initial communication.
The nurse recognizes that the resident has dismissed the first expression of concern regarding a contraindicated medication.
Standard safety protocols require identifying communication breakdowns to trigger formal escalation pathways.
2
Apply the Two-Challenge Rule.
The nurse voices the concern a second time using graded assertiveness (e.g., 'I am Concerned, I am Uncomfortable, this is a Safety issue').
This provides the resident a clear, final opportunity to recognize the safety threat and change the order before formal administrative escalation begins.
3
Activate the immediate chain of command.
The nurse involves the unit charge nurse.
If the Two-Challenge Rule fails, the nurse must seek support from immediate nursing leadership to mediate the cross-disciplinary conflict at the lowest possible level.
4
Escalate to the medical chain of command.
The attending physician is contacted to review the situation.
If the charge nurse and resident cannot resolve the disagreement, the attending physician must be notified to make the definitive clinical decision.
5
Involve hospital administration as a safeguard of last resort.
The chief medical officer or administrator on call is notified.
If the attending is unreachable or agrees with an objectively dangerous plan, administration must intervene to prevent imminent patient harm.

Key Concept

Interprofessional conflict resolution relies on the Two-Challenge Rule followed by a structured chain-of-command escalation to prevent patient harm.
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Topics

Interprofessional Teamwork and Conflict Resolution

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