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

What in the World Is Causing That Stink?

BLUF: Most QI efforts do not fail because the intervention was wrong for the diagnosed problem. They fail because no one found the actual source of the problem. Before you can prevent harm, you have to find its source. That part is harder than it sounds. This is an issue about what happens when I got it wrong.

The first week of January this year, my husband Paul and I were in the living room watching a movie. Paul was recovering from bilateral total hip arthroplasties — which means neither of us was going anywhere — and it was a quiet Minnesota evening until it wasn’t.

The smell arrived without warning.

That is the only word for it. Arrived. One moment the room was ordinary. The next, it was not. Skunk, or something dead — possibly both at once. And did I mention it was January, so there was no way we wanted to open a window.

We looked at each other and paused the movie. It smelled too bad to ignore. Top differential: one of the dogs had brought something inside. We keep the kitchen’s sliding glass door cracked year-round so the dogs can come and go. Second possibility: some critter decided the frigid air outside was no longer worth tolerating and let itself into the warmth of our home. Both plausible.

So, I got on the floor in my own diagnostic hunt for the source of that horrible smell. I had to find the source before I could work on source control. I crawled around the Christmas tree and lifted the skirt. Nothing. Under the couches. Under the chairs. The edges of the rug. The smell seemed stronger in the kitchen — so maybe there — but back in the living room it was stronger again, and in a different spot than before. Bedrooms. Utility room. Bathroom. Nothing. And then, as if it were following me, the odor drifted back into the uliving room and settled. Then back to crawling around on the floor, looking under all the furniture — because that is where it started, right?

I spent more than an hour like this. The smell kept moving through my house. Whatever was making it was not fixed in one place — which meant a critter, maybe even a skunk. It kept appearing somewhere other than where I had just been.

I never once stopped to ask why.

Finally, in frustration, I gave up and reached over to pick up one of my dogs — Paul calls them my anxiety-relieving cuddle devices, which is both accurate and the kindest possible framing of what is clearly a coping strategy. I went to hug the dog.

I nearly fell over.

The source of the smell was my dog! And everywhere I had walked for the past hour, he had followed me. Because that is what dogs do. I would enter a room — nothing. He would settle in beside me — and there it was again.

I had been chasing a moving odor all over my own house and never once considered the source might be one of the dogs.

He had rolled in something — oh, gross! I am still shaking my head that it never occurred to me. More investigating turned up a dead fish in the garden near the kitchen. You may wonder how a dead fish ended up in our garden. We live on the Mississippi River, and one of the quieter gifts of that address is the bald eagles — a dozen of them in winter, perched in a big old dead tree in our yard and using it as a fishing platform. There is also a substantial nest about thirty feet from the kitchen. One of them must have been carrying dinner home and dropped it. The dog found it first.

The fish was frozen solid. This was one of very few moments in a Minnesota January that I have actively thanked God for the cold. A fish on the ground in August, after a week in the heat — I do not want to finish that thought.

Now. Here is the second part that applies to your work.

Paul and I did not agree on what to do about our stinky dog.

My instinct was tomato juice and a full bath — the folk remedy for skunk, close enough. I was going to address the source directly. Paul was convinced the answer was Febreze, which he applied promptly and with confidence while I was still reaching for the tomato juice.

Same dog. Same stink. Same moment in time. Two completely different theories of what would fix it.

Neither of us had stopped to align on the problem before reaching for a solution — and only one of us was going after the source rather than the smell in the surrounding air.

I will let you decide which of us was right.

What could this possibly have to do with Quality Improvement?

It was a LinkedIn post from Jason Meadows, MD — a Physician Quality Leader, former Chief Quality Officer, and host of the Leading Quality podcast — that made me think of this story and the many times I have watched a similar pattern play out in healthcare organizations.

He drew a distinction between first-order and second-order organizations. When a problem appears, a first-order organization asks: What action are we going to take? A second-order organization asks: What system keeps producing this problem?

I recognized myself immediately.

For the first hour of the Great Smell Search of January 2026, I was a first-order organization. I was taking action. Covering ground. Checking every room, lifting every rug edge, crawling across every floor. I was moving — and I mistook the movement for progress. That is one of the most common and least visible mistakes in improvement work.

The second-order question would have been: Why does the smell keep moving?

If I had asked it once, early, I might have gotten to the dog in fifteen minutes instead of seventy.

I commented on Dr. Meadows’ post, because I love his specific call-out: “Our data isn’t changing. We may need to revise our hypothesis.” That sentence nails it. It is the moment the first-order impulse has the potential to become something more useful.

Because here is what I have watched happen in organizations that never develop this skill: they run quality improvement projects that do not target what is actually broken. They target something nearby. Something visible. Something tractable. And sometimes — not always, but often enough to name it — they break something that was not broken in the first place, while the original problem continues on, unchanged.

There is a word for what is needed here. I have used it in clinical practice for thirty years, and I do not think the QI field uses it nearly enough.

Differential diagnosis.

Not of a patient’s symptoms, but of the list of possibilities for which part of the process or system is actually broken; therefore causing repeat measurable harm and no change in our data. The discipline of holding several competing hypotheses about what is producing the problem, testing each against the evidence, and being willing to say — formally, out loud, without defensiveness — our first diagnosis was wrong. Not almost right. Not would-have-worked-if-the-organization-had-been-more-committed. Wrong. And then: re-evaluate the differential. Target the part of the system that is actually producing the harm. The data will move when we get the ‘diagnosis’ correct and target the ‘treatment’. Not before.

Here is the part that sounds counterintuitive.

We must get comfortable with ‘the data not improving’ as a win.

A win?!?

Yes. A win. When the data does not move after an intervention, we just learned something — that what we are doing is not working, which is, if we are honest, exactly the information we needed. As the incurably curious people we are, we now have the privilege of using that to change our approach. To accept that the first diagnosis was wrong. To go back to the differential and look more carefully at what we missed.

That is second-order thinking. That is what Dr. Meadows described. And that is — not coincidentally — what I was failing to do while crawling around my living room for seventy minutes, responding to data I was not analyzing correctly.

The smell kept moving. That was the data. I had it the whole time. I did not see it.

If that resonates — the clinical framework applied to systems, the discipline of differential diagnosis before intervention — it is the intellectual DNA of the Prepare and Prioritize phases of the QI Operating System™.

Prepare is COMMIT and ALIGN. Commit to staying curious enough to keep asking which part of the system is broken — not the closest symptom, not the most visible problem, not the one easiest to address. The source. And align with your colleagues on what you are looking for before anyone reaches for a solution. For the stinking dog — oh, I was committed to finding the source. I just couldn’t see what was right in front of me, and I wasn’t curious enough to stop and ask more questions. I was stuck in first odor thinking and got it wrong. If I had not gotten frustrated and picked up my dog, how much longer would I have crawled around searching for something that was not there?

Prioritize is LEARN and ANALYZE. Going to Gemba — to the place where the work actually happens, to the people closest to it — watching, asking, collecting what they know. And then doing the part most improvement work skips: treating those observations as intelligence rather than just information. A moving smell is data about the nature of the source. I responded to it more than a dozen times, walking room to room, without ever stopping to ask what it was telling me. I had it all along. I just never analyzed it — so I kept collecting more, looking under the couches a second time… and a third. And when we finally realized the dog was the carrier, we both went straight back into first-order source control — I reached for tomato juice and shampoo, Paul reached for the Febreze. Neither of us went out to remove the dead fish. So yes — that means it would happen again. Perfect first-order thinking.

Prepare and Prioritize are the diagnostic phases of the QI Operating System, designed to move your work from first- to second-order thinking. They are the history and physical before the procedure. They are the work of actually locating the stink — and of understanding the mechanism well enough to know what will fix it, rather than what will mask it for the next forty-five minutes.

If you find yourself in the same meeting, with the same problem, hearing the same update for the third quarter in a row — it is worth asking whether your organization is still taking first-order action on an issue that needs second-order problem-solving. Otherwise, as I commented to Dr. Meadows on LinkedIn, we are just the living, breathing definition of insanity: doing the same thing over and over, yet expecting different results.

In our QI Operating System Course, we teach the nuts and bolts of both phases, plus a third called PREVENT, as workflow — not theory. Because most QI professionals already see the second-order problem. You already have the tools. The gap is not the insight. The gap is the infrastructure and system to act on it.

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

Trivia Question for Newsletter Issue #9

Tomato juice as a remedy for skunk odor — fact or folklore?

Hit reply and type your answer. Correct or incorrect, you are entered into the drawing for a $100 gift card. Entries accepted through the end of the quarter. Answer published in the first issue of the quarter.

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@influenceignited.org