Healthcare professional contemplating the balance between infection control and unintended consequences.

Medical

Rhea Morgan in Health & Wellness August 2025 • 4 min read.

"Unintended Consequences in Healthcare: When Good Intentions Backfire"

The Law of Unintended Consequences, a concept well-known in various fields, also applies to medicine. It highlights how actions or regulations meant to improve healthcare can sometimes produce the opposite effect, leading to undesired outcomes.

A prime example is the emphasis on pain management in hospitals. Initially, patient surveys revealed that pain was being undertreated, causing distress. This led to increased opioid prescriptions, which, despite aiming to improve patient comfort, inadvertently contributed to the opioid crisis.

Now, healthcare faces another potential unintended consequence related to value-based purchasing programs like the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS). While these programs aim to improve care quality and transparency, they may inadvertently encourage practices that compromise patient safety.

The CLABSI Conundrum: Are Infection Control Efforts Going Too Far?

Healthcare professional contemplating the balance between infection control and unintended consequences.

The Centers for Medicare and Medicaid Services (CMS) uses the HCAHPS survey to incentivize hospitals to improve care. Hospitals that perform well on quality measures, including those related to infection rates, receive financial rewards. Two key measures are rates of catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI).

The intention is clear: reduce hospital-acquired infections. To achieve this, hospitals have focused on strict sterile techniques during central line placement and maintenance, reducing the duration of central line use, and exploring alternative access methods whenever possible.

More consistent education to the staff regarding the importance of assuring sterile techniques during the placement and maintenance of central venous access.
Reducing the duration of central venous access whenever it is used.
Avoiding it altogether or using an alternative route whenever possible.

However, this emphasis on minimizing CLABSI rates has led to an unintended consequence. Some hospitals are increasingly using peripheral venous access for administering medications and fluids, even when central lines might be more appropriate. In some cases, patients in shock are arriving at tertiary centers with potent vasoconstrictors infusing through peripheral lines, or transfers are occurring primarily because central access is deemed too difficult at the referring hospital.

Finding the Right Balance: Prioritizing Patient Safety in a Value-Driven World

The drive to reduce CLABSI rates is undoubtedly important, but it should not come at the expense of patient safety. Transferring patients solely to avoid central line placement, or using peripheral lines when central access is clearly indicated, can have detrimental consequences.

Studies, like the one by Dillon et al., which examine the safety of administering certain solutions peripherally, are crucial. While peripheral infusions can be safe under specific conditions, more research is needed to determine the limits of peripheral administration, especially for potentially caustic substances. Until then, caution and adherence to established protocols are essential.

Value-based purchasing aims to improve healthcare, but constant vigilance is needed to ensure that these incentives do not inadvertently lead to unsafe practices. Open discussions, data analysis, and a commitment to patient-centered care are crucial to navigate these complex challenges and prevent unintended consequences.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1177/0885066617711422, Alternate LINK

Title: Medicare, Value-Based Purchasing, And The Law Of Unintended Consequences

Subject: Critical Care and Intensive Care Medicine

Journal: Journal of Intensive Care Medicine

Publisher: SAGE Publications

Authors: Mustafa Al-Mashat, Michael Seneff

Published: 2017-12-04

Everything You Need To Know

What is the Law of Unintended Consequences and why is it important in healthcare?

The Law of Unintended Consequences is a principle that highlights how actions or regulations designed to improve healthcare can sometimes lead to unexpected and negative outcomes. It emphasizes that interventions, even with good intentions, can create unforeseen challenges and complexities within the healthcare system.

What are some examples of unintended consequences in healthcare discussed?

A prime example of unintended consequences is the shift towards increased opioid prescriptions for pain management. Initially, this was driven by a desire to alleviate patient discomfort. However, this action inadvertently contributed to the opioid crisis, demonstrating how a well-intentioned policy can lead to harmful results. Another example is the focus on CLABSI reduction, which, while aiming to reduce hospital-acquired infections, has led to practices that could compromise patient safety, such as overuse of peripheral lines.

How do value-based purchasing programs like HCAHPS work and what are their implications?

The HCAHPS survey is used by the Centers for Medicare and Medicaid Services (CMS) to incentivize hospitals to improve care quality and transparency. Hospitals are rewarded financially based on their performance on quality measures, including infection rates like CAUTI and CLABSI. This system is intended to motivate hospitals to prioritize patient care and safety by reducing hospital-acquired infections. However, the emphasis on these metrics may inadvertently lead to unintended consequences if hospitals prioritize them over other aspects of patient care.

What measures are taken to reduce CLABSI rates, and what are the unintended consequences of these measures?

The efforts to reduce CLABSI rates involve strict sterile techniques, reducing the duration of central line use, and exploring alternative access methods. While these measures are crucial for preventing hospital-acquired infections, the unintended consequence is the increased use of peripheral venous access. In some instances, this practice has led to the administration of medications and fluids through peripheral lines when central lines might be more appropriate. This shift can have detrimental effects on patient outcomes and safety.

How can healthcare providers find the right balance between reducing infection rates and ensuring patient safety?

The article highlights the importance of balancing the drive to reduce CLABSI rates with patient safety. The unintended consequences of prioritizing CLABSI reduction, such as transferring patients solely to avoid central line placement or using peripheral lines inappropriately, can jeopardize patient well-being. Ensuring that healthcare decisions are based on the best interests of the patient, considering the full range of clinical needs, is crucial to avoid harmful outcomes.