Learning from Every Patient
A Newsletter for Frontline Healthcare Team Members and Quality Improvement Professionals
Real cases. Practical improvements. Stronger voices at the bedside.
Edited by Jeanne M. Huddleston, MD, MS
From HB Healthcare Safety® and Influence Ignited!
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Patients Caught in the 'Messy Middle'
BLUF: The 'Messy Middle' is not only the gap between leadership and the bedside. It also shows up at the bedside itself — and most of the time, the only person standing in it is the patient and, by extension, their family.
I cared for patients oer the last two weeks. I was intensely reminded about how broken our health care delivery system is. I watched the system fail patients and frontline care team members due to well-intentioned leadership decisions. My previous assumption was that the 'Messy Middle' was just the opaque space between leadership decisions and frontline reality. But while on the wards, I realized that when there is a disconnect between leadership decisions and frontline reality - patients, their families, and the care team members caring for them are smack dab in the middle of the 'Messy Middle'. While the QI Professional has to "wade" in there to fix things... who is going to "wade" in there to get the patient out of the mess?
The contents of that space? Hierarchy, translation gaps, information silos, the experience of being unheard, etc. They not only live between layers of an organization, but also between any two people in healthcare who hold different information, experiences, and powers. A covering pediatrician and a parent. A surgeon and a frightened daughter. An ICU intensivist and a patient's wife who has been at the bedside for six weeks. That is also a 'Messy Middle'. Smaller scale. Same structure.
The three strands that are necessary for us to work our way out of the 'Messy Middle" look the same at the bedside as they do in the boardroom. Clinician intent — what I think good care looks like in this moment. Patient and family reality — what we have already lived, what we already know, what we have already been told by the team who knows our child. And the third strand, the one that does not exist automatically — Translate to Align. The work of making both sides intelligible to each other. Without it, the other two strands run parallel. The encounter ends. Sometimes the family walks out without what they came for.
Most of the time, we ask the family to be the third strand in the braid between their loved one and the clinician... to figure it out... to translate between them. We do not say it that way. But it is what we are asking. The patients who get what they need are most often those with a member willing and able to translate at the bedside in real time. Sometimes, that is a nurse who steps in. Sometimes, a colleague who happens to be in the room. Most of the time, it is the patient's spouse, or parent, or adult child, doing translation work they were never trained for, in a moment when their loved one is at risk. That is not a system. That is not needed infrastructure. That is just pure luck when it works out. And for those patients who do not have a 'translator'?...
The QI Operating System™, our course taking place right now, was created to build and operationalize the processes and infrastructure required to meaningfully connect leadership decisions with frontline realities and patients' needs amid the chaos we call the US healthcare system. Not because families should not advocate — they should, and they will. But because the infrastructure that makes the bedside translatable — clinical context that travels with a patient when their regular clinician is out, warm handoffs that move at the speed of the encounter, communication training that treats translation as a learnable craft rather than a feminine virtue — that is system work. And system work is the third strand needed to form the braid of reliable healthcare delivery.
Not Forgotten - Committing to Learn from Every Patient
BLUF: I, Jeanne, have until now defined the 'Messy Middle" as the space between how leadership views things and the reality of frontline healthcare team members' experiences. I invited Devesh Dahale to share his story because it so plainly illustrates that, very often, it's not just the confusion and internal politics filling in that gap. Our patients get caught in our 'Messy Middle', and somehow we seem blind to it.
Today's story is not mine. A colleague named Devesh Dahale is the author, a father whose son was born with a complex medical condition, and whose family has spent years doing what families in that position do. He gave me permission to publish it here because if you are still at the bedside or have done QI work in any form, you will recognize the pattern. Not the family. Not the medication. The encounter spiraled because the people in the room were working from different scripts and with different information, and there was no infrastructure to close the gap between them.
Here is Devesh.
Not Just a Simple Refill
It had been six years since our son was born.
Six years of learning what it means to parent a child with a birth defect.
It was simply the hand he was dealt.
Those years were filled with surgeries, risks, and constant vigilance. His condition came with other anomalies. Infections were always a threat. Medications were not optional; they were protective. Somehow, through careful management and sheer resilience, he made it through infections that could have taken far more from him.
We lived in Minneapolis. His specialty care was in Cincinnati. That distance mattered. It made every decision heavier and every oversight more dangerous. If you have ever cared for a child with a complex chronic condition, you understand this tension. You live in a state of constant readiness.
At the time, he was waiting for urology surgery. A high-grade urinary reflux was suspected, though the confirming test had not yet been done. In his case, a fever was rarely “just a fever.” It usually meant a urinary tract infection. Since our last visit to Cincinnati, he had been on a low-dose antibiotic. It was meant to protect him during a vulnerable window before surgery.
Then came a gap in communication. His prescription refills expired.
Our regular pediatrician was out of town.
We saw another doctor covering for her.
The visit should have been simple.
All we needed was the same prescription, same dose, same plan that had already been established.
It was not simple.
The covering pediatrician questioned why our son was still on antibiotics.
At first, we were confused.
Then patient.
Then frustrated.
We explained his history. We explained the risks. We explained why this medication mattered.
But we were not being heard.
Without taking time to understand our son or his story, the doctor lectured us. He said he could not prescribe antibiotics “in good conscience” without symptoms.
Then he added something that changed everything:
“If it were my son, I would not give him these unnecessary antibiotics.”
That sentence landed hard.
Years of fear, exhaustion, and friction with the healthcare system surged to the surface.
I responded in anger. I told him plainly that our son was not his son. I asked him to stop projecting and simply do his job. I asked him to help us protect our child. From there, the encounter spiraled. Voices rose. Positions hardened. We left without the medication our son needed.
Later, my wife tried again. She spoke calmly. She asked for just one refill. She said we would use it only if needed. That approach worked. The prescription was filled just in time. A few days later, the doctor called and apologized. He admitted he had not understood the gravity of the situation or how vulnerable our son was without that medication.
Looking back, the questions linger.
What if we had given up?
What if we had trusted authority over lived experience?
How is parent advocacy received in modern healthcare?
When doctors are trained to follow guidelines and metrics, where do individual stories fit?
Why was my reaction dismissed while my wife’s was accepted?
What finally broke through — empathy, reflection, or discomfort?
We do not have clear answers.
But these questions are not theoretical. They sit at the center of the doctor–patient relationship. They shape outcomes. They expose cracks in a system that often rewards box-checking over listening. Algorithms and protocols can guide care, but they cannot fully capture the reality of a child whose life depends on nuance.
This was only one moment in our son’s long healthcare journey. But it matters. It reminds us that advocacy is not optional. It reminds us that being right is not the same as being heard. And it reminds us how fragile trust can be when curiosity is replaced by judgment.
This story, like so many others, should not be forgotten.
- Devesh Dahale
The Loved-One Lens
"If it were my son, I would not give him these unnecessary antibiotics."
That sentence is the hinge of Devesh's story. It sounds like empathy. It functions like its opposite. And the reason it functions like its opposite is the subject of next week's newsletter.
For today, just this.
There is a difference between a clinician asking what would I do if this were my child?
And a clinician asking if this were my child, is there anything I would want to go differently for him?
Different question. Different answer. Most of us were trained on the first. Few of us were taught the second.
I want to name something else in the story before I close.
Devesh's wife got the refill.
Same child. Same prescription. Same covering physician.
Different delivery.
She asked for one. She said they would only use it if needed. She gave him a smaller, safer decision than the one he had just refused — and he could say yes to it.
That is translation. She was able to speak in a way that the clinician heard her.
It is not a feminine virtue. It is not a temperament. It is not that she is "better with people."
It is a learnable skill for healthcare team members
Yet we often shift this responsibility to families and expect them to perform at the bedside in real time every day.
The pediatrician was not a bad doctor. He was a good doctor standing in for a colleague without the infrastructure he needed to do the job well. He had good intentions. Good intentions are not infrastructure. He called back days later to apologize, and that matters — but the system that put him in that room without the context he needed is not fixed by his apology.
In the next newsletter, we will go deeper into the Loved-One Lens — what it actually asks, why so many of us have been using it backward, and what it makes possible at the bedside when we use it the way it was designed.
Devesh — thank you.
Trivia Question for Week of April 10, 2026
Trivia Question: The phrase primum non nocere — "first, do no harm" — is widely attributed to the Hippocratic Oath. Is it actually in the original Hippocratic Oath?
Just hit 'reply' and type an answer. You will be entered into the $100 gift card drawing.
By learning from every patient we encounter, we will have the data and the stories needed to influence improvements.
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 fix the harm they see happening every day. Each issue features rotating content, including real cases, expert commentary, a “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
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