While Theresa Brown’s “inside nursing” op-ed might be seen as limited to the sphere of hospitals, it’s not.
The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait. I first heard about it from Karen Feinstein, the president and chief executive of the Jewish Healthcare Foundation, who reported it at a board meeting several years ago. I wasn’t surprised: Hiding common medications is a workaround, an example of circumventing onerous rules to make sure patients get even basic care.
Workarounds are legion in the American health care system, to the extent that ECRI (formerly the Emergency Care Research Institute) listed them fourth among its list of top 10 patient safety concerns for health care organizations in 2018. Workarounds, the group writes, are an adaptive response — or perhaps one should say maladaptive response — to “a real or perceived barrier or system flaw.”
Hiding drugs above a ceiling tile might strike a familiar chord for criminal defense lawyers, but that’s not the point. The point is systems. The point is rules and regulations created to fix the problem of the moment or adopt the shiniest new tech device, or as has happened in New York after the last election, rushed complicated criminal law reform at the behest of activists whose grasp of how courts function is tainted by their undue passion.
Systems are created with an idea, usually well-intended, in mind, but almost invariably depend upon the hard work, competence, dedication and shared goal orientation of every hand required to make the system function. In a hospital, that assumes the administration, doctors, nurses and Sid in Accounting are all on the same page, working toward their mutual goal of keeping costs down and opening new revenue streams, treating patients and getting prompt and complete insurance reimbursement.
Or perhaps their interests aren’t the same at all. Perhaps their interests are in conflict with each other, and keeping Sid happy means a few patients die while waiting for medications to be properly scanned so they can be billed.
Workarounds in health care always involve trade-offs like this, and often they are trade-offs of values. Increasingly, the entire health care system is built on workarounds — many of which we don’t always recognize as such.
To some, one more rule, one more tweak to the system, will solve everything. Of course, we’ve been making rules, tweaking systems, for a very long time and yet everything remains unsolved. Whether the problem resides in needlessly complicating a process because there will always be some outlier problem that outrages or saddens the passionate, giving rise to the ubiquitous cry that “something must be done” or the steadfast belief in a fantasy grasp of humanity, that we are all dedicated to the greater good rather than ourselves or even the pedestrian performance of our positions, we keep complicating systems until they crash.
The United States spends more per person on health care than any other industrialized country, yet our health outcomes, including overall life expectancy, are worse. And interventions like bar code scanning are a drop in the bucket when it comes to preventable medical mistakes, which are now the third-leading cause of death in the country. Our health care nonsystem is literally killing us.
For the most part, the legal system isn’t “literally killing us,” although that’s true for some and figuratively for many. No matter how swell our intentions, how pressing the need, the more complicated we make our systems by grafting more rules and procedures, requiring more fingers pushing the right buttons at the right times, the more likely we are to have something go wrong. The answer to every system failure may not be to make the system even worse. It goes for medicine. It goes for law as well.