Recently, I came across a quirky little behavioral science investigation that looked into a surprisingly contentious issue: why people don’t return their shopping carts. The researcher spent months observing parking lots in the same way an ecologist might observe a watering hole, cataloguing the excuses, social cues, and micro-calculations behind a behavior that most of us never think twice about. The whole thing was amusing at first blush, but the deeper I got into it, the more unsettling it became. The patterns she uncovered were instantly recognizable to anyone who has spent time inside a modern healthcare system.
Because when you peel back the comedy of the parking lot, you’re left with a truth that echoes uncomfortably in hospitals everywhere: systems often fall apart not because of dramatic failures, but because of small, ignored responsibilities that everyone silently assumes someone else will handle. Healthcare, it turns out, has a shopping cart problem.
When small acts become cultural signals
The most striking finding from the shopping cart research wasn’t that people sometimes skip the long walk back to the corral - it was the way those individual choices combine to create a visible, legible culture. One abandoned cart becomes another person’s permission slip. A row of carts left haphazardly along the curb announces, without anyone saying a word, that returning carts is no longer the expected behavior. The descriptive norm (the “what we actually do here”) quietly overtakes the injunctive norm (the “what we’re supposed to do here”).
Anyone who has walked the halls of a hospital at shift change has seen the healthcare equivalents. Undocumented findings left for the next physician to take care of. “Normal” imaging results sitting unacknowledged for days because “someone will notify the patient.” Best practice recommendations overridden reflexively without real consideration. These aren’t dramatic failures - they’re tiny ones. But the culture they create is powerful, and usually not in a good way.
Healthcare’s most persistent operational problems are often the sum of these micro-abandonments. No one plans for it; no one chooses it. But over time, the small scraps of unclaimed work pile up until the entire system feels slower, heavier, and more contentious. A clinician who starts the day already frustrated by the digital clutter left behind by their colleagues is not in the mood to talk about “joy in medicine.”
The psychology of letting things slide
The article identified a series of explanations people offered for abandoning their carts. Some said they were in a hurry. Some believed the task was beneath them. Some assumed an employee was waiting to collect the carts anyway. Some looked around, saw a lot of other stray carts, and concluded that was simply how things worked.
If you replace “cart” with “chart,” “result,” “inbox message,” or “decision-support notice,” the parallels are almost perfect. Clinicians are genuinely busy, often with competing priorities that would flatten someone in a less chaotic profession. But busyness doesn’t fully explain why certain tasks fall by the wayside while others never do. Instead, the tasks that get left behind are the ones framed as clerical rather than clinical, optional rather than essential, anonymous rather than meaningful. When a task appears to exist primarily to satisfy a system’s need rather than a colleague’s well-being or a patient’s safety, it is destined to become the healthcare equivalent of a cart perched on a planter.
Hierarchy also plays its part. Just as some shoppers consider cart return the job of “someone lower on the ladder,” certain workflows are quietly viewed as chores for someone else, even when that “someone else” ends up being an equally overburdened colleague in the next shift. And, inevitably, the descriptive norm resurfaces: if everyone else leaves their work half-done at this particular touchpoint, why should I be the person who breaks the norm?
The hidden costs that leaders rarely see
Abandoned carts in a parking lot mostly create inconvenience. In healthcare, the costs are far more profound and far less visible. A clinician who opens their workday to discover a dozen unattended tasks from a prior shift enters that day already underwater. A nurse who repeatedly encounters incomplete handoffs begins to distrust the system itself. A care team that can’t rely on closed loops quietly becomes a care team that double-checks everything, which is both exhausting and operationally expensive.
These small breakdowns ripple outward. They add friction to patient flow. They slow throughput in ways that don’t show up neatly on dashboards. They require new hires to spend a surprising amount of time cleaning up messes they didn’t create. They chip away at the delicate sense of professional reciprocity that keeps exhausted clinicians willing to go the extra mile for their colleagues.
The uncomfortable truth is that leaders often miss these micro-failures because they’re designed to be invisible. They hide behind big-ticket organizational priorities like AI roadmaps, workforce strategies, enterprise analytics plans, or clinical excellence frameworks. But if a health system hasn’t figured out how to encourage and reinforce small responsible behaviors, all the large strategic bets get dragged down by the weight of everyday disorder.
Toward a culture where returning the cart is the norm
Solving this isn’t about shaming anyone, neither shoppers nor clinicians. It’s about designing a system where the right thing is easier, more visible, and more normal than the alternative. That starts by making the stray carts impossible to ignore. When people see the magnitude of unfinished tasks, whether it’s open charts, unacknowledged results, or sky-high override rates, they start to realize the culture they’re participating in. Transparency isn’t punitive; it’s clarifying. It turns an abstract problem into something tangible.
But visibility is only the beginning. The real shift happens when the culture frames these small tasks not as clerical burdens, but as professional commitments. A well-designed handoff isn’t a bureaucratic requirement; it’s an act of courtesy to the next clinician who will care for the patient. A closed chart isn’t a box checked for compliance; it’s one less landmine for the night team. When these actions are tied to identity, reciprocity, and respect, they stop feeling like chores and start feeling like culture.
And yes, incentives matter: not grand financial ones, but subtle, timely, well-designed nudges. A quick reminder to close remaining tasks before leaving the unit. A note celebrating a week of on-time handoffs. A gentle social comparison showing how most peers complete certain workflows promptly. Behavioral science has no shortage of ways to align digital behaviors with human tendencies. Healthcare just has to decide to use them.
All of this is easier if the workflows themselves don’t resemble an uphill cart return in a snowstorm. Friction breeds abandonment. Thoughtful design reduces it. No amount of motivational messaging can compensate for poor UX, redundant steps, or alert spam.
The path forward
The shopping cart metaphor lingers because it reveals how culture really works. Systems don’t fall apart when someone fails spectacularly. They fall apart when hundreds of small actions slide just a bit off course. Over time, those little deviations calcify into routine. And before anyone notices, the parking lot – physical or digital – has become cluttered enough that no one remembers what “normal” looked like.
It’s tempting for leaders to focus on big, strategic initiatives, and we should. But we should also walk the figurative parking lot of our health system and notice the small things people leave behind. Not to punish anyone, but to understand the environment clinicians are navigating.
Returning the cart is not about the cart. It’s about belonging to a system where everyone trusts that their colleagues will meet them halfway. Healthcare, more than any other industry, depends on that shared understanding. And unlike in a grocery store, when the carts pile up here, it isn’t someone’s bumper that gets dented – it’s someone’s health.