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

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Advancing Healthcare Improvement Science

BLUF: Healthcare systems generate two strong, yet disconnected, lines or strands: leadership intent and frontline reality. The BRAID framework adds the missing strand needed in healthcare improvement science—translation and alignment—so those foundational strands can finally braid together into lasting improvement.

For the past two decades, healthcare has increasingly embraced Improvement Science — a field focused on systematically studying how care systems can become safer, more effective, and more reliable. Yet even as the science of improvement advances, many efforts still stall in practice. Not because the tools are wrong, and not because the data are missing, but because healthcare systems naturally generate two powerful strands that often run in parallel and remain disconnected: leadership intent and frontline reality.

Leaders set priorities, strategies, and governance structures. Frontline clinicians experience workflow friction, patient signals, and operational complexity. Between these two strands lies what I call the messy middle — the space where disciplines collide, hierarchy filters signals, and meaning gets lost.

The BRAID framework begins with a simple insight: lasting improvement requires a third strand that does not automatically exist inside most healthcare organizations. This strand emerges when someone works the messy middle and performs the critical work of translation and alignment.

Frontline observations must be translated into system insight using leadership language. Leadership priorities must be translated into operational meaning using patient stories that support the front lines. When that translation happens effectively, the strands begin to weave together. Shared understanding emerges across disciplines, trust grows between teams, and improvement work becomes coordinated rather than fragmented.

Learning to perform this translation is the core skill of the BRAID framework. It is not limited to those with formal authority; in fact, some of the most powerful improvement work comes from people willing to step into the messy middle and connect perspectives that normally remain separate. When leadership intent, translation, and frontline reality finally braid together, healthcare systems move beyond good intentions and isolated projects toward something far more powerful: alignment that produces lasting improvement.

Leadership provides intent.
Frontline teams provide reality.
The BRAID framework teaches us how to connect them.

Join us to learn more during a free webinar on Thursday, March 19, 2026 at noon CT. https://us06web.zoom.us/meeting/register/14JBMjIeTUWzeraw12QEDA​

Tied Down: The Amazing Grace of a Stuffed Dog Named Marshall

BLUF: We don’t know what we don’t know.

John’s Intubation-Extubation Yo-Yo

John was admitted to the medical ICU with a severe COPD exacerbation. His wife and three adult children were present when he made his wishes very clear — including his desire to be intubated if necessary.

He was intubated, responded well, and was extubated within 36 hours… only to aspirate and require reintubation. This cycle repeated two more times.

Through all of it, John remained cognitively intact, with a great sense of humor. Every time we revisited goals of care, he reaffirmed the same thing: keep going.

John was a wonderful human being, and his family was incredible. They didn’t just support him — they checked in on the care team when the ICU felt especially chaotic. Within two weeks, his room walls were covered with drawings from his many grandchildren.

Because he tolerated ventilation so well, we kept him lightly sedated so he could interact with his family and the team. Even without a voice, his warmth came through like a shining light.

Quiet Unease

One afternoon I stopped by his room just to check in. The atmosphere felt different.

In only a few hours his respiratory status had worsened dramatically — fever, new infiltrates, rising oxygen requirements. The fatigue on his face showed how hard his body was fighting.

He was septic.

At the family’s request we waited for his children and held a care conference. The plan was to treat aggressively and reassess in three days. John himself said that if he didn’t turn the corner, he wanted to talk about comfort care.

The Moment That Stayed With Me

Before heading home that evening, I stopped by his room again.

The sun was setting through the window. The room was quiet. John was alone — except for a new stuffed dog on his bed, a gift from his youngest grandson.

I sat between the bed and the window just watching.

Then I noticed something that made no sense.

John was restrained.

In two weeks of respiratory failure he had never once required restraints. He had never pulled at a tube or line. Not once.

The sepsis had made him groggy, but he was still cognitively intact when you spoke to him.

The nurse was new to John — floating from the trauma ICU. She told me she had “caught him” trying to self-extubate, so she restrained him.

It still didn’t make sense.

I had been in that room day and night for fourteen days. John had never reached for a tube.

As I sat there quietly, he slept… occasionally lifting his hand slowly toward his face — only to be stopped by the white cloth restraint.

A Small Act of Rebellion

I couldn’t keep watching.

The nurse declined my verbal order to remove the restraints. So when she stepped out of the room, I untied them myself. Let’s just say I didn’t make a new friend that day.

I promised that if he reached for his tube, I would restrain him myself.

Then I sat and waited.

When his hand lifted again toward his face, I held my breath.

His arm moved slowly — so slowly it felt like time had stopped.

His finger reached his nose… where the feeding tube was taped.

He scratched his nose.

Then his arm dropped back to the bed.

The Stuffed Dog

We often say: we don’t know what we don’t know.

But sometimes we also don’t notice what is right in front of us.

In a busy ICU, it is easy to move quickly. Easy to assume. Easy to reach for the fastest answer.

That day the fastest answer had been restraints.

I woke John and told him the story.

Then I placed the stuffed dog on his shoulder.

“John,” I said, “if you move your hand toward your face and feel the dog, your hand is too close. The nurses will worry you might accidentally pull the tube.”

The dog was named Marshall — my maiden name.

Marshall stayed on John’s shoulder after every linen change and repositioning.

The Ending

Three days later it was clear John wasn’t turning the corner.

One new organ was failing each day.

John decided it was time to transition to comfort care.

The next morning his family stood around the bed holding hands.

His son — the father of the little boy who had brought the stuffed dog — stood at the foot of the bed and sang the most beautiful tenor Amazing Grace I have ever heard.

As he sang, I gave the morphine.

And the respiratory therapist gently removed the tube.

Learning from Every Patient Newsletter Trivia Question

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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.

Next Webinar: Thursday, March 19 @Noon CT - Link below to register

​https://us06web.zoom.us/meeting/register/14JBMjIeTUWzeraw12QEDA​

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