Learning from Every Patient (#8)

A Newsletter for Frontline Healthcare Team Members and Quality Improvement Professionals

Real cases. Practical improvements. Stronger voices at the bedside.

From HB Healthcare Safety® and Influence Ignited!

Edited by Jeanne M. Huddleston, MD, MS ____________________________________________________________________________________

By learning from every patient we encounter, we will have the data and stories we need to influence the minds and hearts of our leaders. We do not need positions of authority to create improvements.

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Angie's Purpose

BLUF: The story you are about to read happens a thousand times a day in American hospitals — and we do not need to be helpless to lean in and make a difference for some of our most vulnerable, yet difficult, patients.

I’m handing the page over this week to Angie Filipiak, a “retired” nurse manager who watched a patient with dementia try to climb out of bed and listened as her team worked through the usual options. Sitter. PRN. Restraints. Each one explainable in the chart. Each one with its own risks. None of them what Angie reached for.

What she did instead wasn’t in a guideline. It wasn’t in a clinical decision support tool, and it isn’t going to be any time soon. It worked — not because the intervention was clever, but because of what she was actually looking at when she chose it.

Read her story first. I’ll meet you again down her page.

Angie’s Story

By Angie Filipiak

In the fast-paced environment of a medical-surgical unit, patient safety is always a priority—but for patients with cognitive impairment or dementia, safety often requires a different kind of thinking. During my time as a nurse manager, I saw firsthand how challenging it could be to care for these patients in a setting that can feel unfamiliar, overstimulating, and even frightening.

One patient’s story has stayed with me. Lynn had once been a NICU nurse—a caregiver who spent her career nurturing the most vulnerable. But now, as a patient with advanced dementia, she was in a very different place. She became increasingly restless and agitated, frequently calling out for her baby. She was impulsive and trying to climb out of bed. Traditional redirection wasn’t working, and a medication felt like a last resort, as it's important to avoid, as the side effects can further increase fall risk.

The staff, in a moment of creativity and compassion, tried something simple. They gathered towels, rolled them up, and handed them to her to hold. Using a Sharpie, they drew a small smiley face on the fabric. It gave her something tangible—something to comfort and occupy her hands. It wasn’t perfect, but it helped tremendously.

That moment sparked an idea that would ultimately shape the trajectory of my nursing career. Not long after, I brought a baby doll into the unit, thinking it might provide comfort for patients experiencing similar distress.

A few weeks later, another patient with dementia was admitted. She was restless, yelling out, repeatedly attempting to get out of bed. Her bed alarm sounded constantly, and the team grew increasingly concerned about her safety. During a multidisciplinary discussion, we began considering next steps: a safety sitter, PRN antipsychotic medication, or even restraints. All valid options—but also more restrictive, more resource-intensive, and not without risk.

When I heard she had dementia, I suggested we try the baby doll. The impact was immediate. As soon as the doll was placed in her arms, her demeanor changed. She became calm, focused, and visibly comforted. She stopped trying to climb out of bed. The yelling ceased. Instead, she gently held and interacted with the doll, as if reconnecting with a deeply rooted sense of purpose and familiarity. That simple intervention prevented the need for more invasive measures.

This experience reinforced something important: sometimes the most effective solutions aren’t found in orders or protocols, but in understanding the person behind the patient. For individuals with dementia, tapping into past roles, identities, and emotional memories can be incredibly powerful.

Moments like these didn’t just change patient outcomes—they changed me. This work became my purpose: to find more compassionate, person-centered ways to care for individuals with cognitive impairment and to help others see what’s possible beyond traditional interventions.

Caring for patients with cognitive impairment will always come with challenges. But experiences like these show that with empathy, creativity, and a willingness to think differently, we can create safer, more dignified experiences—for both patients, their families, and our caregivers.fortable.

My Reflection: The Loved-One Lens

I keep returning to something in this newsletter I call the Loved-One Lens. I imagine my mother in the same scenario, which has happened. At that moment the questions I was asking were not about ‘what I would want’, they were about what would restore my mother’s comfort, peace, and grace. These are much harder questions and require us to pause and consider who, in this case, Lynn was in her prime.

The Loved-One Lens asks something very hard… when we have absolutely no time to pause. How do we ask not what I would want, but rather, who is this person, and what does she need?

Look again at what Angie did. She didn’t ask what she would want if she were the one in the bed. She asked who Lynn had been — and the answer was right there, in the calling out. Lynn wasn’t confused. Lynn was a NICU nurse. She had spent a career holding babies. When her cognition slipped, the part of her that remained was the part that had always reached for an infant. The “agitation” was a woman returning to her purpose and finding no baby in her arms.

A rolled towel with a smiley face on it is not only a clever intervention… it is the right intervention because someone on that unit saw Lynn before they saw the bed alarm.

This is what we teach in our QI Operating System Course — that the frontline is not the place where improvement gets implemented… it is the place where improvement is created and can gain momentum… if harnessed. Angie’s team didn’t need a protocol. They needed someone to notice that no protocol could see what they could see. The job of the QI professional is to find solutions like this one, name them, translate them, and keep them from being lost when leadership shifts goals, staffing changes, the unit reorganizes, or the next “best practice” arrives.

Picture someone you love who has reached an age where her own children’s names will not always come back to her. Picture her in a bed she does not recognize, in a gown she did not choose, calling out for something the room cannot give her. Ask not what you would want done. Ask what she would need to feel like herself again — and trust the team at her bedside to know it before you do.

That is the Loved-One Lens. That is the work. Thank you, Angie, for sharing such a beautiful example of this from the nurses on your floor, and from you. We share your purpose!

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Meet Angie at our next Collaborative Conversations: an open webinar for everyone in advancing care for our nation's most vulnerable... the elderly and cognitively impaired... patients like Lynn and my mother.

Forward this information to anyone who has the clinical and QI experience paired with a passion to make care better fore the most vulnerable.

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The QI-Operating System Course: What This Cohort Made Visible

Five weeks with a cohort of senior QI professionals confirmed what Angie’s story already names — the people closest to the work are the ones generating the solutions, and most of them have been doing it without an operational language for what they are doing… they just do “what is right” based on instinct and compassion.

The cohort wraps up this Friday. Senior QI professionals, patient safety coordinators, risk advisors — from health systems of various sizes and a patient safety organization. I love teaching and built this curriculum around my personal failures and successes expecting to teach participants an operating system for QI work. What I did not expect was how much of it they were already running — in pieces, by instinct, from years of doing the work without ever having the shared language to teach someone else how.

One participant — a patient safety leader with decades in the field — described how she takes any meaningful change to senior leadership. She meets each leader one-on-one first. She makes sure their individual questions are answered before the room ever convenes. She knows the feel of the room before she walks in. And she brings a frontline leader with her so that the people in the meeting understand the change is not in her head — it is what is actually happening at the front line. That is Translate to Align. She has been doing it her entire career.

A second participant described what happens to the team members on the inside of a serious safety event. They lose grace for themselves. They are the second victims of the same failure. We have all seen it. This is the Loved-One Lens extended past the bedside. The same moral discipline that asks who Lynn was before the dementia has to be applied to the clinicians who absorb the consequences when systems break. It is why the closing line of every issue of this newsletter names both roles.

A third participant described a pattern any senior QI professional will recognize. If you do this work well, you are given more of it. One area of responsibility becomes fifteen. The cost is not only to you — it is also to the teams who report to you and lose your guidance when you are stretched to thin, and to the programs that touched the front line and started to fail because the structure could not hold. This is why in our course, the COMMIT step precedes the ALIGN curriculum. The discipline of declining the additional scope is not an afterthought; it is the entry point into the operating system. A QI professional who cannot decline cannot protect the work they have already committed to.

The pattern Angie named at the bedside is the same pattern this cohort surfaced from inside the system that does not always see them. The work is the same. The Lens is the same. What changes is the room you are standing in?

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Remember... behind every QI project is a patient, and healthcare team members, who need us to finish.

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Trivia Question

This issue’s question: Which British psychologist, working in the late 1980s and early 1990s, developed the concept of “person-centered care” in dementia practice and argued that personhood is sustained by relationship even when cognition declines?

Reply to the newsletter trivia question email for a single entry into our drawing for a $100 gift card. Correct or incorrect answer doesn’t matter — you will be included. Each newsletter has a different trivia question and you can reply once per newsletter. Names go into the drawing through the end of the quarter. The winner will be notified by email and the answer published in the following newsletter.

About this Newsletter

Learning From Every Patient is a case-based patient safety and quality newsletter for frontline clinicians and healthcare quality improvement professionals who want to stop preventable harm. Each issue features rotating content, including real cases, expert commentary, a short “Loved One Lens” reflection, a brief look at “what worked” in successful improvement efforts, tips and tricks for quality improvement and patient safety projects, and quick scans of relevant new evidence. Published by HB Healthcare Safety, SBC, and powered by Influence Ignited!, the newsletter is edited by Jeanne M. Huddleston, MD, MS, and is designed to turn everyday stories and process defects into practical, actionable lessons you can use on your next shift.

Editor: Jeanne M Huddleston, MD, MS