Patient safety and medication reconciliation
Learning from Every PatientA Newsletter for Frontline Healthcare Team Members and Quality Improvement ProfessionalsLife in the trenches. Real cases. Practical improvements. Stronger voices at the bedside.
Answer the Trivia Question for a Chance to Win a $100 Gift Card!Read to the bottom to find the trivia question and instructions. We will draw the winner's name on the first day of next quarter. The answer and lucky winner will be shared by email and announced in the following Newsletter! I'm Lucky That I Didn't Hurt AnyoneBLUF: The only thing standing between three patients and a medication error that night was sheer luck. Not a system. Not a safeguard. Just me — sleep-deprived, alone, on my sixth of seven consecutive night shifts — and the fact that I had not yet hit submit on my orders. That is not a safety system. That is a coin toss. I am surprised at how vivid the picture is in my head. And that this is the first time I have told this story completely. I was working nights primarily at that point in my career. My kids needed me during the day, and nights were how I made that possible. I can’t remember whether Paul was deployed in the Middle East at the time — although it would contribute to an overall state of heightened anxiety I carried into every shift. It was roughly 1:00 a.m. I had been told five admissions were coming. None had arrived yet. And then, within approximately fifteen minutes, three of them showed up — on three completely different medical floors. At the same time, a patient already in the hospital was becoming more acutely ill and could require the ICU. And I was getting paged about yet another admission still to come. I had two phones in the room and several computers. I was by myself. On one phone, on speaker, I was listening to an intake report from the ER. In my left hand was another live line — on hold with the VA, trying to arrange a transfer for a stable patient. And I had the electronic health record open with all three newly arrived patients, working through preliminary admission orders. Pages were already coming from the nurses. One patient was hungry. Another had a family member who needed to talk to me before they left. What occurred to me as I worked through the orders is that these three patients — heard about hours apart — had arrived within fifteen minutes of each other. And they were all women in their mid-to-late 80s. Hypertension. Coronary artery disease. Hypercholesterolemia. Stage 3 chronic kidney disease. Heart failure. Early cognitive decline. All on similar classes of medications — yet different medications and doses within those classes. I started rolling through the medications case by case. Into the third patient, I realized I no longer remembered which patient was which. Which medication in which class belonged to which woman. Let alone the doses. I remember sitting there exactly like I’m sitting right now. Left leg crossed over the right. Leaning over with my left elbow on the desk and my head propped in my left hand. Wondering how I could have screwed up so badly. I had not yet hit submit. But I realized how close I was to causing harm. __________________________ What I did next came from fifteen years of patient safety training. I stopped. Closed everything. I called the pharmacist for patient one — gave them the name, medical record number, and admitting scenario and asked for a thorough medication reconciliation. I paged the nurse practitioner for patient two and asked her to do the same. I took patient three myself. There were errors. In one case, the dosing of the same medication between two patients. In another, I had picked the wrong medicine within the same class. All caught. All near misses. None reached a patient. I did not report any of it. _________________________ What stays with me is not the errors. It is the question I could not answer that night: what do clinicians do in that moment when they do not have the training to know it is okay to stop? When they do not know who to call? When they are alone at 1 a.m. and cannot see their way out of crushing information overload? The system did not fail because I was careless. The system placed one physician — sleep-deprived, alone — managing three simultaneous admissions of nearly identical patients across multiple floors, a deteriorating patient, and a demanding family with no structural safeguard between my fatigue and a medication error. That is not a personnel problem. That is a process failure. What near-miss events still haunt you years later? I told one of mine. I would like to hear yours. Reply to this email — I read every one. If You Are Going to Change a Process, Who Actually Has to Change?BLUF: The highest-risk clinical moments — overnight, understaffed, cognitively overloaded — are precisely the moments least likely to generate a report. If quality improvement does not go there, it is solving the wrong version of the problem. Let's take my story as an example of a series of events that could trigger a QI project in everyone's favorite area: medication reconciliation (read: sarcasm dripping off the words "favorite" and "med rec" in the same sentence). If a QI professional is going to lead a project on medication reconciliation at admission, then we all know that it is essential to have a deep understanding of the current state. However, do we all understand that it means recognizing the pressures within the system that may cause the process to operate differently? Such as days when staffing is at its highest versus nights when there is an entirely different set of challenges? One patient at a time, versus a bolus of patients at once? Thinking back to my experiences in the middle of the night, consider this. If your med rec project were to be successful, you would need to understand what it's like to do the work under multiple sets of pressures. Unfortunately, this would mean some pretty inconvenient data collection at undesirable times. The process map has to include the moment when one person is holding two phones, four records, and three nearly identical patients, and the only thing between those patients and harm is whether that person has the wherewithal to stop when they sense things going sideways. Think about it even beyond the data collection... that visual of the middle-of-the-night chaos... you need that person to change their behavior. No change in my behavior when ordering medications = no change in your med rec reliability metrics. That is not a tools problem. We have the tools. It is an operating system problem — knowing how to enter the space where the work actually happens, deeply understanding the cultural and clinical context, and translating what you find there into something the frontline is willing to engage on and the leadership can hear and act on. I spent thirty years learning that operating system the hard way — including the night I almost made three medication errors in fifteen minutes. I turned what I learned into a course because I believe anyone willing to step into this space can learn to do this work without having to collect all my bumps and bruises. The QI Operating System (QI-OS) Course starts tomorrow, and we are accepting enrollments through April 17 at noon CT. If this story sounds familiar to you, it would be an honor to have you in the virtual room. QI Operating System (QI-OS) course information: https://hbhealthcaresafety.org/QI-OS Newsletter Trivia QuestionIt is simple. 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 will have a different trivia question, and you can reply once for each question. This means that your name can go in the drawing up to 12 times each quarter (once for each newsletter published). As long as you respond to any of these newsletters, published during the quarter, before the end of the quarter, you will be included in the drawing. We do the drawing on the first day of each quarter. The winner will be notified by email, and the answers to the question are published in the Newsletter. Trivia Question for Week of April 10, 2026Trivia Question: The concept of “stop the line” — empowering any worker to halt production when they spot a problem — originated at which company’s manufacturing plant? Just hit 'reply' and type an answer. You will be entered into the $100 gift card drawing. About this NewsletterLearning 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. “Remember that behind every QI project is a patient and healthcare team members who need us to finish.”Editor: Jeanne M Huddleston, MD, MS
|
Learning from Every Patient
Learning from Every Patient presents real patient cases and practical lessons that help healthcare teams prevent system failures, reduce suffering, and save lives. Editor Jeanne Huddleston, MD, MS.