Five Jabs in the Arm

At the hospital, a young girl who had broken her arm was waiting for care. The kindly middle-aged nurse was inserting an intravenous port in preparation for surgery to repair the damage and set the bones. On the first try, the nurse missed the vein, and apologized to the girl and parents for the discomfort. On the second try, she again missed, and the girl began to cry. On the third failed attempt, the girl was howling, and the nurse was weepy, frustrated and apologetic. She sought out the help of another nurse who had "softer hands" and was better with the IV's. The new nurse tried, the fourth time, and again could not locate a vein. Everyone was in tears now, tears of pain and frustration, and tensions were running high.

In exasperation, the nurse slammed down the troublesome IV port and said "These things are useless. Give me a minute." She returned a short while later with a different IV port and easily inserted it into a vein; everything calmed down and went smoothly from then on.

In conversation with the nurse, she revealed that a few months previously, purchasing had switched to a new supplier of intravenous ports. Her understanding was that the cost was about five percent less for the new ports. "...but they're terrible. I've got the 'best hands' so they ask me for help, but these new ones just don't work. I've got a small stash of the old ones but we're running out of them and I don't know what we'll do when they're gone. I wish they'd asked us before they changed."

So, the purchasing department saved some money and was probably celebrated for cutting costs. But the increased costs in labour for the nursing staff, and in pain and suffering for the patients, more than outweighed the savings. So often, we make one small area "better" in a way that makes the whole system worse. Just say no to sub-optizimation!