Which action demonstrates escalation of unsafe orders?

• A. Document the call and give the medication.
• B. Call the HCP again for clarification.
• C. Notify the charge nurse and activate chain of command.
• D. Refuse to document the event.

Answer: (C)

Escalation of unsafe orders means actively seeking higher-level review to stop or correct an instruction that could harm a patient. When a medication order or directive seems unsafe or unclear, the nurse should not proceed on their own. instead, inform the charge nurse or supervisor and activate the chain of command so a higher-level clinician can re-evaluate and intervene if needed. This step provides formal accountability, ensures patient safety through proper safety protocols, and initiates timely corrective action.

Documenting and giving the medication would carry out the unsafe order rather than challenge it, which is not escalation. Calling the HCP again for clarification is helpful for clarification, but if the order remains unsafe, escalation to a higher authority is still required. Refusing to document the event avoids accountability and does not escalate the issue.