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

A note of gratitude before we begin.

Thank you to each of you who reached out to me directly or to a member of my team during my unexpected absence over the last 6 weeks. I stopped writing completely when my father became suddenly ill. I had the honor of being his caretaker at his home in hospice. Everything happened so fast, and I am still struggling to wrap my brain around the viciousness of pancreatic adenocarcinoma – three weeks from first symptoms with an ED visit/CT scan to last breath. There will be more coming. It is just a little too soon.

And a name we owe you.

In the quiet of early July, our quarterly drawing did not happen on time. It has now. The winner of the Q2 $100 gift card is Bridget Burke! Thank you to everyone who wrote in this spring — your replies are the entire reason this section exists. Keep them coming. Read to the very bottom for this newsletter’s question.

No Courage to Make Eye Contact

BLUF: Blame worsens it; systems thinking heals it.

This newsletter is doing something pretty special. People are sending me their stories, their nights of moral injury, the weights they carry even years after the event. We all have those stories. This story is not mine, but was shared with me by a nurse who experienced the humiliation of working in an environment completely lacking ‘Just Culture’.

She was on her fourth night shift in a row. Short-staffed — the kind of short that has quietly stopped being an emergency and become the accepted staffing plan. Six patients. One of them was a man in his forties, post-operative, who should not have been on her floor at all. The surgical unit was full. So, he was boarded on a medical unit, cared for by people trained for a different set of problems than the one he brought with him.

His problem was post-op pain.

The physician who admitted him had written for acetaminophen as needed for pain. Tylenol. For a man fresh out of surgery. By the time she met him his pain was a six and climbing, and within a couple of hours it was an eight and he was crying — the kind of crying grown men do only when they have run out of other options. She did what you are supposed to do. She paged. She got a verbal order for something that would actually work.

And here the system she worked inside began, at first quietly, to fail her.

The hospital ran verbal orders on paper. A fax. A thirty-minute turnaround on a good night, layered on top of the very electronic record everyone was also charting in — two systems bolted together at a seam, and the seam was where her patient was waiting. Thirty minutes became an hour. The order reached a pharmacy that was, in her word, slammed. Another two hours, they told her. Her patient had by then been crying, on and off, for the better part of four.

She went to her charge nurse. The charge nurse told her to override the Pyxis.

I want to slow down here, because this is the moment that, in retrospect, fell seam apart, and it lasted about fifteen seconds.

She stood at the Pyxis at the far end of a long night and typed in the needed medication. The screen offered her the choices it offers everyone — Percocet, Norco, Roxicodone, stacked one on top of another, names that share letters and syllables and, to a tired eye at three in the morning, very nearly share a shape. She selected. A colleague co-signed the override and saw exactly what she saw. She carried the pill to her patient. His pain came down to a three. He slept.

But wait… doesn’t that sound like a win? She advocated for her patient and his suffering was alleviated. Unfortunately, she had pulled the wrong one. Oxycodone-acetaminophen instead of hydrocodone-acetaminophen — two combination tablets that do the same job, at doses close enough that the pharmacist who caught it the next morning noted the patient had come to no harm. Which is the part everyone would later manage to forget.

Now count the decisions that led to that medication delivery.

A patient boarded on the wrong unit because another unit was full. An admitting order for Tylenol — and nothing for breakthrough pain — on a post-surgical patient. A verbal-order process run by fax in a building full of computers. A pharmacy with no way to triage a suffering patient to the front of the queue. A charge nurse who authorized a workaround because the sanctioned path had already failed twice. And a screen that displayed three look-alike opioids side by side, with nothing between them but one nurse’s exhausted attention. Another nurse who validated her selection.

Not one of those is a nursing decision. Not one of them was in her control. Every one of them is a system condition. The error was built upstream, over months, by people who were not in the room that night — and then a structurally broken process was handed to one tired person standing at a machine, as if it had been her personal design all along.

Weeks passed. Then she was called, without explanation, into a meeting.

Three people were waiting. The director. Her nurse manager. A representative from human resources.

What happened in that room she told me in a detail I will not fully reproduce, because she lived it once and does not need it published back to her. The shape of it was this. The director pointed at her, as though she was a child being disciplined. She was told she was a nurse, not a doctor. That she had been “prescribing like a physician.” She apologized. It was not accepted. She apologized again, and a third time, and each apology was judged insufficiently remorseful. And then she was told, plainly, that she would say the words “I am a bad nurse” — or be written up.

Her nurse manager sat beside her the whole time with his hands folded in his lap and his eyes down. He did not look at her. He did not speak. The HR representative shifted in her seat and said nothing at all.

She said the words.

The director smiled and told her she was free to go.

She left the room on legs that would not quite hold her. She found the day-shift nurse manager and sobbed. She did not sleep. In time she left that hospital for another one. The director retired not long after. So did the person from HR.

The fax machine, as far as anyone knows, is still there.

I know something about overriding a system for a patient. I have done it myself.

Years ago, I cared for a man — I have called him John in these pages before — for fourteen days in a medical ICU. Severe lung disease, his body failing him, his mind entirely intact. One night a nurse floating in from another unit told me she had caught him trying to pull out his breathing tube, and his hands were restrained by the time I arrived. He had not been pulling the tube. He had been reaching for his nose, where a feeding tube was taped, because it itched. That was the whole of his crime.

I asked for the restraints to come off. The nurse declined my verbal order. So, when she stepped out of the room, I untied them myself. Let’s just say I did not make a new friend that day.

In a busy ICU, or med floor, it is easy to move quickly. Easy to assume. Easy to reach for the fastest answer — and that night, for someone without fourteen days of knowing him, the fastest answer had been restraints. She was not wrong because she was careless. She was wrong because she lacked the one thing she was never given — context. I had it. She did not.

So I made her a physical symbol to translate John’s needs into something unmistakable. I set a small stuffed dog — Marshall, named for me using my maiden name — on John’s right shoulder, where anyone walking in would see it and know, without being told, that this was a man who was known.

Now hold the two nights side by side.

A nurse overrode a sanctioned path — a Pyxis, a pharmacy queue — to relieve a suffering patient, on the direction of her charge nurse, and made a look-alike error the system had all but drawn up for her. A physician overrode a sanctioned path — a colleague’s judgment, a refused order — to relieve a suffering patient, entirely on her own authority, and untied a restrained man with her own hands.

Both of us were right about the patient. But both of us stepped outside the lines. Mine was, by any honest accounting, the larger act of rebellion. I overrode a person. She overrode a queue.

I won’t go into other stories now, but there are dozens of times in my career that I have gone around, over, under, or through broken, yet sanctioned, policies to get done what a patient needs and get it done efficiently.

I have never been called into “that” room. No one ever sat me down between a director and someone from HR and required me to say out loud, “I am a bad doctor.” The difference between her morning and my absence of one was not the act, and it was not the outcome. It was the letters after our names. Two bedside clinicians did the same thing — broke through a poorly written, sanctioned path to put the needs of a patient first. Yet “they” reached out to the nurse and forced humiliation upon her, while allowing me to walk without rebuke. In fact, we were both rewarded by our patients — mission accomplished. Our patient’s needs were met.

Somewhere in the weeks between that pill and that meeting, an incident report was filed. And that report was the moment — the exact moment — when a quality professional should have been standing in the gap — the gap between frontline care team members and leadership.

There was the frontline reality: a postoperative man crying out at eight-out-of-ten pain for hours because of a fax and a long queue. And there was the leadership response: a meeting run as a character assassination. Between them was the Messy Middle, one that completely lacked ‘Just Culture’. No one waded into that Messy Middle. No one translated the frontline truth into something leadership could act on. No one translated leadership’s legitimate worry about a medication error into the only question that could have made the next shift safer — what in our building made this error this easy? Why wasn’t anyone on the QI team, who received the incident report and is trained in Safety II and peer support principles, there to provide the accurate context?

Had someone done that work, that incident report would produce a review of the verbal-order fax process and a hard look at a Pyxis screen that lines up three look-alike opioids like a trap. It produces a safer next shift. Instead, it produced a “false” confession — and changed nothing that would keep the next good nurse from staring at that same screen, making the same decision for her patient.

My Reflection: After 30 years, shouldn't we be better than this?

BLUF and a little bit of ‘high horse’: I am personally ashamed of a system that can still persecute its own. Naming a person as the problem is not only operationally inaccurate, but also organizationally destructive, and morally reprehensible. Inaccurate, because the broken processes of care that we can all point to are engineered upstream. Destructive, because the moment you make a person the defect, you have closed the only door that leads to a safer building… and that causes moral injury no matter your profession.

We manage doctors and nurses differently when something goes wrong. I do not say that as an accusation — I say it as someone who has spent a career inside it and benefited from it without asking to. When a physician is involved in an unintended harm, I have seen the reflex be either what happened or what were they thinking. Many of my colleagues will push back on that because we have all been shamed in peer review. But I do think there is a structural difference in how the professions’ view and manage patient safety events. When a nurse is involved, the reflex by other nurses is to ask what is wrong with her. A human standing in a failing system. You cannot fix a pharmacy staffing issue by shaming the nurse standing next to it.

There is a name for what she became when she put the needs of the patient first – “second victim”. It was the moment that changed her entire career trajectory. She is a a clinical team member wounded by her own involvement in a patient’s near miss. Something like half of us meet it at least once in a career; among emergency and ICU nurses, roughly a quarter describe a distress that they can only call extreme and pervasive. And the researchers who study how second victims recover gave one of the stages a strikingly honest name — “enduring the inquisition.”

So let me ask the question I ask about every case — the Loved One Lens question. If this were your loved one, could you sit and watch it happen? Or would you get up and make it better without hesitation?

Picture the patient first. The man in the bed. Forties, post-op, on the wrong floor, crying and suffering for four hours because of a fax and a queue that existed because of understaffing in the pharmacy. If that is your brother, your son, your father — would you choose to file a policy change request to fix the queue during the next business day? Or would you do whatever possible to get him the medicine?

Now turn the lens — and this turn is the whole discussion for me. Picture the nurse in that chair, being told to call herself a bad, while professional “leaders” just look down at their own hands — they do not have the courage to make eye contact. Make her your daughter. Your sister. Your mother. Or even yourself — ten years and one bad night ago. The same instinct that will not let you watch a patient suffer should not let you watch that either.

The Safety II heuristic does not change when the person who needs protecting moves from the bed to the bedside. The people caring for our patients deserve exactly what our patients deserve — a system that does not set them up to fail, and leaders who, when it does, refuse to name a human being as the defect.

This is the work our QI Operating System Course was built to teach: how to stand in that gap to translate and navigate those, at times, very turbulent and ugly waters in the Messy Middle. It goes both ways – top down and bottom up. This case illustrates that we need more of us to wade into the Messy Middle, not just for our patients, but for every one of us who has ever been standing at the bedside when the system failed. And our next course is starting in August.

The QI Operating System Course

You’ve got all the tools – shoot, we have too many tools! Now let’s navigate the complexities of the structural divide – designed into the system - between leadership intent and frontline reality. Our highly matrixed organizations require the QI professionals to translate organizational goals to people who are just trying to survive their next clinical day, create process change without personally ever working in the process, and wrangle changing human behavior [Yep, Huddleston, you have to admit patients 100+ miles away without ever touching them.]! I can’t think of a single PDSA cycle that can make all of that happen.

After 30+ years in the patient safety and quality improvement trenches, I cataloged my QI failures and successes. There were some commonalities between what I did and what I missed that led to the outcome achieved. This is what I teach.

August 21, 2026 – we go live with the first of 5 weekly live content and discussion sessions, live Q&A, private 1:1 coaching, tools to improve your leadership skills, and a host of other things to make your job possible.

​https://hbhealthcaresafety.org/QI-OS/ to register.

Join us! SLS Collaborative Members participate at no cost – contact Alyson at johnson@influenceignited.org!

Trivia Question for Newsletter Issue #10

Who coined the term “second victim” — the clinician who is wounded by their own involvement in an unintended patient harm — and in what year?

Reply to this email with your answer for a single entry into our drawing for a $100 gift card. Correct or incorrect doesn’t matter — you’re in. One reply per newsletter. Answer with each newsletter and get multiple changes to win! 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 issue.

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, 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 possibly quick scans of relevant new evidence. Published by HB Healthcare Safety, SBC, powered by Influence Ignited! LLC, and edited by Jeanne M. Huddleston, MD, MS. It 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@influenceignited.org