The need for ongoing change within the US healthcare system is warranted. However, before implementing change, advanced notice is given and explicit instructions on how the change will happen should certainly be considered for those who will be directly impacted. Sterman (2006) explains decisions made in one part of the system ripple out across geographic and disciplinary boundaries. Change occurs at different rates and scales within and among systems, especially in healthcare (Spath & Kelly, 2017). In this case study, the patient was not given any inclination that her medication costs would change prior to arriving at the pharmacy, thus causing a huge cascade and a total inconvenience for the patient. Probably the biggest change to the patient's life is financial status, due to now being a widow and having a fixed income. This enormous change to the patient's income would significantly affect her ability to afford out-of-pocket costs for essential needs such as medication. Again, had this patient been given prior knowledge about insurance provisions for medication, she could have made an informed decision.

Trading one medical service, product, or treatment for another is one other way the US healthcare system experiences qualms. This particularly comes into play with medication replacement. For example, in the scenario, the patient was forced into having received a new, less expensive medication that ultimately caused a rippling effect of medical travesty and ended in her death. Once again, there was an opportunity to inform the patient before her going into the pharmacy and learn that she would have to pay far more for her prescribed medication. Moreover, trade-offs, as it relates to healthcare, is often related to what an organization, insurance company, and or stakeholder is willing to compromise on. According to Spath & Kelly (2017), a decision to compromise could affect patient outcomes and unintentionally contribute to polarization and conflict between clinicians and managers.

In healthcare, there are things done traditionally one way or another. But, when change is impending this causes a level of anxiousness among most stakeholders. Spath & Kelly (2017) discuss the fact that history dependency can be seen in both the organization and the patient. Additionally, not all implemented changes can be undone and may issue permanent consequences. Some actions taken are reversible, while some cannot be overturned (Spath & Kelly, 2017). In the scenario, the patient was given a new, less expensive medication, however, perhaps the primary physician neglected to educate the patient about the potential side effects of taking certain over-the-counter medications alongside the new medication. Unfortunately, the medication interaction caused a domino effect and ultimately resulted in the patient's death. Any clinical actions leading up to this patient's death could not be undone, only modified for the next patient that experiences something similar.

Tight coupling is a fundamental part of any healthcare system. Spath & Kelly (2017) explain healthcare organizations often demonstrate loosely coupled social structures such as departments, divisions, and professional groups, yet tasks carried by the microsystems in the organizations are often tightly coupled. Additionally, in a tightly coupled system, it can be difficult for people to recognize and correct mistakes to prevent an undesirable outcome (Spath & Kelly, 2017). For example, cardiologists, x-ray technicians, and nurses belong to separate, distinct, loosely coupled professional groups and departments, yet when they come together in a cardiac catheterization lab, the tasks performed during an angiogram procedure are tightly coupled (Spath & Kelly, 2017). In this scenario, seemingly there was no sense of tight coupling. From the primary physician to the pharmacist, the patient was not informed about the potential effects of the new medication coupled with any over-the-counter medications. There was no tight coupling collective effort of educating the patient in this scenario.

A nonlinear healthcare system is often potentially inequitable and disproportionate for any stakeholder (Spath & Kelly, 2017). According to Spath & Kelly (2017), in a nonlinear system, small deviations may have huge, unpredictable, and irregular effects. In this scenario, there was a huge consequence for the change in medication and lack of patient education provided, and this is certainly considered a nonlinear effect.

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