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OB Guideline 5: Resolution of Clinical Discord

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OB Guideline 5: Resolution of Clinical Discord

Related to: Clinical Guidelines, Communication, Diagnosis, Documentation, Nursing, Obstetrics

Each institution shall have a formal process to resolve disagreements between professional staff about medical management, conduct of labor, or interpretation of tests of fetal status. The process should consider these points:

  1. Priority should be given to maintaining safe, quality patient care.
  2. In cases of discord, the involved parties shall first discuss the discord and attempt to resolve it. The “two challenge rule,”1 and other methods of conflict resolution may be considered to facilitate structured communication and avert medical errors .2,3
  3.  If the involved parties cannot resolve the discord, they should seek assistance, initiating the chain of command4 through medical, resident/fellow  supervisory  physician, midwifery, and/or nursing hierarchy, as indicated .5-7  A list of medical staff, supervisory physician, midwifery, and nursing hierarchy should be available in the clinical areas.
  4. All discussions pertaining to differences in clinical opinion should occur among professional staff only, and out of earshot of the patient and family.
  5. Differences in clinical observations and opinions should be documented in an objective, non-argumentative fashion in the medical record.
  6. Unexpected medical incidents relating to the discord should be reported to the institutional risk manager.
  7. The occurrence of the discord should be reported to the Chief of Obstetrics, the Director of Nurse Midwifery, and/or the Obstetrical Nursing Director, as indicated.


  1. Assertively voicing your concern(s) at least twice to ensure your concerns have been heard by your colleague.
  2. MacReady N. Two-challenge rule averts errors improves patient safety. OR Manager. 1999;15(1):12.
  3. Marshall P, Robson R. Preventing and managing conflict: vital pieces in the patient safety puzzle. Healthcare Quarterly. 2005;8:39–44.
  4. The chain of command is a series of steps ascending the administrative and clinical lines of authority established to ensure effective conflict resolution in patient care situations.
  5. Patient safety in obstetrics and gynecology. ACOG Committee Opinion No. 447. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114:1424–27.
  6. American Nurses Association, (2001). Code of Ethics for Nurses with Interpretive Statements, Washington, D.C. American Nurses Publishing.
  7. American College of Nurse Midwives. Code of Ethics. 2005. Reaffirmed 2008. Available at: http://www.midwife.org/ACNM/files/ ACNMLibraryData/UPLOADFILENAME/000000000048/code%20_of_ ethics_2008.pdf

 

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May 1, 2014
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