Examkin

Question

Difficulty: HardInterprofessional Teamwork and Conflict Resolution

A multidisciplinary team is managing an 82-year-old man admitted for community-acquired pneumonia. On hospital day 4, his respiratory status has normalized, but he remains severely deconditioned, requiring maximum assistance for bed-to-chair transfers. The attending hospitalist enters an order to discharge the patient to his home, where he lives with his frail 80-year-old wife.

The primary nurse approaches the hospitalist and says, "I am concerned about discharging this patient home today because his wife cannot safely assist with his transfers."

The hospitalist replies, "His pneumonia is clinically resolved. He does not meet acute inpatient criteria anymore, so we need the bed."

The nurse then explicitly states, "I am uncomfortable with this plan; it is a significant patient safety issue for him to go home without physical rehabilitation established."

The hospitalist responds, "That is an outpatient care coordination issue. Please process the discharge paperwork."

According to standard interprofessional patient safety and communication frameworks, which of the following is the most appropriate next step for the nurse?

  1. A
    Document the disagreement thoroughly in the electronic health record and execute the discharge order.
  2. B
    Transfer the patient to a different medical unit to delay the discharge until a new attending physician takes over.
  3. Escalate the safety concern through the nursing chain of command to engage the medical director.Answer
  4. D
    Initiate a root cause analysis of the hospital's discharge criteria to prevent similar future events.
  5. E
    Report the attending physician to state adult protective services for intentional elder endangerment.

Answer

The most appropriate next step is to escalate the safety concern through the nursing chain of command to engage the medical director.
The correct action is to escalate the safety concern through the formal chain of command. In standard patient safety frameworks (such as TeamSTEPPS), the CUS tool (I am Concerned, I am Uncomfortable, this is a Safety issue) is used to clearly highlight a threat. This functions synergistically with the Two-Challenge Rule, which requires a team member to voice their concern at least twice if the first assertion is ignored. In this scenario, the nurse successfully executed both challenges. Because the attending physician explicitly dismissed the second challenge and insisted on proceeding with a high-risk action, the protocol dictates that the nurse must not proceed. Instead, the nurse must activate the formal chain of command (e.g., contacting the charge nurse or nursing supervisor, who will then contact the departmental medical director) to resolve the impasse before the patient is harmed.

Step-by-Step Solution

1
Analyze the communication framework already utilized by the nurse.
The nurse stated, 'I am concerned' (Challenge 1), and after dismissal, stated, 'I am uncomfortable... patient safety issue' (Challenge 2).
This confirms the nurse correctly applied the CUS (Concerned, Uncomfortable, Safety) tool and completed the Two-Challenge Rule.
2
Determine the outcome of the Two-Challenge Rule.
The attending physician dismissed the second challenge and insisted on proceeding with the unsafe discharge.
When a critical safety limit is reached and the Two-Challenge Rule fails to resolve the issue, standard patient safety protocols must dictate the next action.
3
Identify the protocol-driven next step for an unresolved critical safety issue.
The nurse must 'stop the line' and escalate the issue through the formal administrative or clinical chain of command.
Escalation ensures that higher-level leadership (e.g., nursing supervisor and medical director) mediates the conflict before the patient is subjected to an unsafe disposition.

Key Concept

When the Two-Challenge Rule fails to resolve a critical patient safety issue among interprofessional team members, the immediate next step is to escalate the concern through the formal chain of command.
Rate this question

Topics

Interprofessional Teamwork and Conflict Resolution

More questions from this topic