Learning from Every Patient

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

Is Mortality Review Dead?

BLUF: Mortality review fails not only when the reviews stop, but also when the reviewing only feeds a database… not learning.

I have heard that question more than once in recent weeks. Not from cynics. From serious, committed quality leaders who are exhausted, under-resourced, and watching their organizations dismantle the very infrastructure that was supposed to catch what everything else missed.

I understand the instinct to question it. It is appropriate when nothing is changing because of it.

But I am not ready to pronounce it dead. So why are some places saving lives and increasing their star rating while others do not?

I have been doing this work for 23 years, so it’s just a little embarrassing to tell you that I finally had a moment of clarity this week.

The Whiteboard Moment

So I am standing at the whiteboard in my dining room — my trusty colored markers in hand.

On one side: “Making a difference” — decreased mortality, readmissions, ICU length of stay, and end-of-life suffering.

On the other: “No difference” — no improvement in metrics.

A question mark in the middle.

___

I mapped it out - me and my colored markers. I stared at it for longer than I care to admit.

And then I felt something I can only describe as engineering shame.

I should have seen this sooner.

___

After all, the answer is in the name.

Mayo Clinic Mortality Review System

Safety Learning System Collaborative

Workflows designed by an industrial/systems engineer.

Hello McFly?!?!?

Case Review (Mortality or Otherwise) System

Where mortality review is dead: Case reviews in isolation — as a component of their quality strategy, yet seemingly disconnected from everything around it. The reviews happen → data accumulates. A seemingly impenetrable wall between the database and proactive targeted improvement activity.

Where mortality review is alive and kicking: Case reviews are tightly and intentionally integrated into the core quality work. Systems have inputs and outputs. These facilities have mortality reviews as the input and well-developed mechanisms for output — analysis built into the workflow, meeting cadence with senior leadership, accountability built into their strategic objectives, and an operational plan to strategically target the most common process failures.

I am not prepared to watch it disappear into binders and spreadsheets.

____________________________________________________________________________________________

We Won’t Forget You

BLUF: Not targeting the common process failures reported by frontline care team members, or those found in mortality reviews, has a consequence.

Mable was a frail, independently living (she would not leave her farm) 91-year-old. She managed her daily life, kept her routines. Her daughter called every afternoon without fail and visited at least twice a week.

One afternoon, Mabel didn’t answer the phone. That had never happened before.

Her daughter went immediately to the house and found her on the floor — sometime in the night, she had gotten up to use the restroom and fallen. She had been there for hours. Severe right hip pain. Unable to move. Unable to reach the phone.

She went by ambulance to the emergency department. Orthopedic surgery evaluated her. She was admitted to hospital medicine and underwent surgical repair of her hip fracture the following morning.

Intra-operatively, she developed significant hemodynamic instability — severe heart failure — requiring more vasopressor support than usual. Postoperatively, she was transferred to the ICU.

She woke up confused. Not surprising with baseline cognitive impairment + anesthesia + opioid + ICU environment with prolonged hypotension.

She was eventually transferred to a general medical floor, awaiting nursing home placement.

On the fourth day of hospitalization, she developed respiratory distress. They assumed aspiration because she had an emesis episode as soon as she tried to eat her first meal in bed. Semi-recumbent.

Mabel was urgently transferred back to the intensive care unit. Her daughter decided not to proceed with the impending intubation. After a failed attempt with BiPAP, she became comfort care only and died.

She Was Not The Only One

Over a span of two to three months, two other hip fracture patients experienced identical presentations and hospital trajectories — surgical repair of fracture, intraoperative hemodynamic instability, ICU stay, aspiration with the first meal postop, transfer back to the ICU in acute respiratory failure, decline of intubation, and death.

Three hip fracture, elderly patients. The common experiences were undeniable. It was time to sit with the charts together — a multidisciplinary group, walking through each patient’s experience side by side — and find the exact point in the process where this particular group of vulnerable patients had slipped through a gap -- one that the other ninety percent did not.

The team assigned to do this work had just finished a two-year aspiration prevention project. They were in the room. And they were mortified. One of them asked out loud whether they were going to have to start all over again.

They were not.

Hope and Potential

The gap? Hip fracture patients are NPO on admission for emergent/urgent surgery. No 3-ounce water screen. Four days pass in the hospital, two transfers postop, then no aspiration risk assessment before feeding. After all, it’s been four days — and that is done at admission… right?

The order to do the screening was still present, but it was so buried it could not be seen with routine EMR view. The fix could be as simple as adding a 3-ounce water screen when a diet is changed from NPO in patients at risk.

The team recognized it the moment it was named. The room felt different. The aspiration prevention team understood, visibly, that their two years of work was intact. There was one gap, located precisely, with a repair that seemed straightforward and feasible.

They knew the gap, could specifically define the vulnerable group of patients, and had a potential solution. It was a good moment.

This is Hard Stuff

That was two to three years ago.

The electronic re-prioritization of the order to do the 3-ounce water screen for at-risk patients when they get their first feeding order… didn’t happen.

There are so many reasons why even the seemingly easy projects just don’t get done. We all know the list. We’ve all heard the reasons — shoot, I’ve participated in the creation of the list of why something won’t work.

A 2026 study published in JAMA Network Open adds important data to a picture those on the frontlines can already paint. When we see the same harm happen again and again — whether in direct patient care or case reviews — something in us takes a hit.

There is distress that comes from knowing the right answer, yet being unable to act on it.

Knowing where the protocol has a gap and being unable to close it… while understanding that the inaction means we will watch another vulnerable patient fall through that gap.

That is what the seemingly impenetrable wall between collecting data and doing something about what it tells us actually costs. Not just in outcomes, but also in the people at the bedside — and who will carry the weight of what they found long after the data moves to the next dashboard cycle.

This is why mortality review without a proactive integration into a system is not just inefficient. It is, eventually, distressful to the people who do it well.

What We Control

For those hip fracture patients, I cannot eliminate the risk of aspiration in a facility many states away. I have no influence with their leadership, and I don’t work there.

But I have agency.

I use the Loved-One Lens heuristic in every case I review. This time it is my Grandmother. She had two hip fractures, a couple of years apart. Visualizing her face as I wrote about this group of patients changed my practice permanently.

Now, any time I walk into a patient room, and there is a frail elderly patient eating a meal, semi-recumbent in bed, I very politely remove the tray. You can just imagine the look on their face when I do that… not to mention the look on the nurse’s face.

I find the right care team members and together ensure that every measure of our aspiration prevention protocol is in place — including sitting upright in a chair to eat. And yes, I do rewarm their food as needed.

It takes a few minutes. It is time I choose to use, if there is even a chance this action will prevent an episode of aspiration.

_______________________________________________________________________________________

Not Forgotten

How about you? Use your Loved-One Lens for a moment.

It is not rhetorical. It is an operational instruction. It is what turns a protocol into a presence and a data point into a human being eating lunch.

Picture the oldest, most frail member of your family.

In bed. After surgery. Delirious.

Eating. Semi-recumbent in bed. Drugged.

Would you want them to have the aspiration prevention screen? Would you want someone to move the food tray if they were eating and risk had not been assessed?

By learning from every patient we encounter, we will have the data and the stories needed to influence improvements.

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

_______________________________________________________________________________________

What This Means for Your Work

What I know from 23 years of this work is that the system can be built. The wall can come down. It requires connecting the trigger to the response, the input to the output, the learning to the action. It is a skill. It is teachable. And it is exactly why BRAID: The QI Operating System Course began registrations this week for our next small cohort beginning April 10.

​Click to Learn More About the Course​

_______________________________________________________________________________________

Quarterly Newsletter Trivia Question

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.

Trivia Question for the Week of March 26, 2026

What does the HB in HB Healthcare Safety stand for? Hint: it is our mascot… an animal with two names.

H_______ B_______

_______________________________________________________________________________________

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

Founder, Influence Ignited, LLC

Co-Founder, HB Healthcare Safety, SBC

Professor of Medicine, Mayo Clinic College of Medicine

huddleston@hbhealthcaresafety.org OR huddleston@influenceignited.org