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COLUMNS
Nudging Towards Safer Decision-Making in Healthcare
With complex and dynamic healthcare systems, along with an under-resourced and overburdened healthcare workforce, how can we best avoid errors and secure patient safety?
by Laís Junqueira

In recent years, the impact of evidence-based decision-making on patient safety has been under close examination. Despite technological advances, the gap between theory and practice remains a challenge to both clinicians and allied health professionals. Due to the complexity and dynamics of health systems, “doing the right thing” is not always as straightforward as it may seem.

According to the World Health Organization’s (WHO) Patient Safety Action Plan 2021-2030,1 it is estimated that one in 10 people in high-income countries are harmed while receiving hospital care, and up to 15 per cent of hospital spending is due to safety failures in care.2,3 This differs from low-and middle-income countries, where it is estimated that one in four patients is subject to harm.4

An important part of this issue is medication safety. Unsafe medication practices and errors are a leading cause of avoidable harm in healthcare systems across the world.5 During the COVID-19 pandemic, healthcare professionals (HCPs) were increasingly under-resourced and overburdened, which significantly exacerbated the risk of medication errors and associated medication-related harm. It is in this context that medication safety was selected as the theme for the recent World Patient Safety Day 2022.6

There is no doubt that health information technology is an important tool to facilitate the delivery of high-quality care. By digitalising manual tasks such as prescriptions and introducing technological innovations such as medication alerts and clinical reminders, there is an opportunity to improve patient safety by enhancing evidence-based decision-making.

How Clinical Guidelines and Technology Support Patient Safety

The use of clinical guidelines and evidence-based guidance is considered essential practice for improving quality and patient safety.7 Clinical guidelines are evidence-based recommendations intended to optimise patient care. Guidelines have the potential to influence care outcomes, but for that to be possible they must be implemented effectively.

Technology provides the opportunity to enhance patient safety by digitalising evidence-based guidance to improve clinical decision-making. More specifically, the use of “nudges”—a behavioural economics concept,—presents a great opportunity to guide clinicians towards safer decisions. Considering decision-making as an important element of safer systems in healthcare, there is an increased need to foster effective and improved dynamics between people, processes, knowledge, and technology to generate an output of safety.

Merging Clinical Knowledge and Nudges in the Workflow

With the time pressures and competing priorities that clinicians routinely face, most end up using intuitive, non-analytic, implicit, and biased processes to a greater degree than analytical reasoning. While this rapid decision-making strategy can save time, it is more error-prone when patient cases are complex, and HCPs are stressed or rushed. Therefore, there is an opportunity to support clinicians to make more informed decisions through nudges.

Nudges, as described by Nobel Prize award winner Richard Thaler and Cass Sunstein, are a tool designed to optimise choices by encouraging safer and healthier behaviours. A fundamental aspect of a nudge is the maintenance of individual freedom of choice. This means that even though choice architecture encourages you to make a certain decision, the option to follow through with the prompt is still yours to make.

A clinician or institution’s immediate environment and choice architecture should be purposefully designed in a way that directs them towards the provision of safe care for patients and stakeholders respectively.

For example, a group of Japanese patients received differently-designed client reminders from their healthcare provider for optional hepatitis virus screening before their general health check-ups. The patient screening rate for those who received reminders designed using the nudge theory showed how modifying client reminders using nudges significantly increased hepatitis screening uptake.8

Changes to the way choices are presented and information is framed within the Electronic Health Record (EHR) can lead to significant differences in the way clinicians order tests and treatments. Nudges that show a comparison of clinicians’ prescription rates have been successfully used to encourage clinicians to prescribe fewer antibiotics for acute respiratory tract infections. It has even increased influenza vaccination rates through the usage of active prompts for doctors in the electronic health system.9 A survey of 166 primary care providers in Chicago has also shown that rearranging the visual display of treatment options in the EHR, to nudge appropriate prescriptions, has led to an 11.5 per cent reduction in choosing aggressive treatment options.10

Encouraging Informed Decisions

Nudges for HCPs can range from reminders of standard operating procedures to active support for clinical decision-making. Consider the scenario of a nurse starting a shift at an intensive care unit (ICU) and being given a postsurgical case. The nurse logs into the EHR and checks the care plan for that patient, which suggests the parameters to be measured and actions to be performed based on patient assessment and best available guidance. For this patient, blood loss management is included, and subsequent actions are based on a clinical practice guideline. The nurse’s clinical decision is nudged by both a checklist and guidance, avoiding errors of omission, and nudging them towards evidence-based practice.

Nudges for clinicians aim to improve the workflow and steer decision-making towards evidence-based care by reducing the know-do gap (the gap between what we know in theory and what we do in practice).

In Australia, the Victorian Government Nudge Unit partnered with St. Vincent’s Hospital Melbourne to increase attendance rates at outpatient appointments and found that those patients who received personalised appointment reminder texts, as opposed to other text types, were more likely to attend their specialist clinic appointment.11

Looking Ahead

In the wake of the pandemic, NHS workforce shortages are at an all-time high as clinicians are navigating record-breaking backlogs and patient waitlists. Clinicians are being asked to do more with less time. This disruption has emphasised the role evidence-based clinical knowledge and digital technology can play to improve patient safety.

Knowledge-driven digital technology can be combined with choice architectures that nudge healthcare providers towards safer decisions. As systems progress and evolve, healthcare leaders have the opportunity to act as decision-environment architects.

References:

  1. World Health Organization. (2021, August 3). Global Patient Safety Action Plan 2021-2030. World Health Organization. Retrieved from https://www.who.int/publications/i/item/9789240032705
  2. Slawomirski, L., Auraaen, A., & Klazinga, N. S. (2017). The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: Organisation for Economic Cooperation and Development; 2017
  3. Auraaen, A., Slawomirski, L., & Klazinga, N. (2018). The economics of patient safety in primary and ambulatory care: flying blind. Paris: Organisation for Economic Cooperation and Development; 2018
  4. Health Systems Strengthening Glossary. Geneva: World Health Organization; 2011 (https://www. who.int/healthsystems/Glossary_January2011.pdf, accessed 12 July 2021).
  5. World Health Organization. (n.d.). Medication without harm. World Health Organization. Retrieved from https://www.who.int/initiatives/medication-without-harm#:~:text=Unsafe%20medication%20practices%20and%20medication,of%20the %20medication%20use
  6. World Health Organization. (2022, September 17).World patient safety day 2022. World Health Organization. Retrieved from https://www.who.int/campaigns/world- patient-safety-day/2022
  7. Clinical Practice Guidelines: Closing the Gap Between Theory and Practice – Joint Commission International. JCI-Whitepaper_CPGs-Closing-the-gap-between-theory-practice.pdf (clinicalkey.com)
  8. Fukuyoshi, J., Korenaga, M., Yoshii, Y., Hong, L., Kashihara, S., Sigel, B., & Takebayashi, T. (2021). Increasing hepatitis virus screening uptake at worksites in Japan using nudge theory and full subsidies. Environmental Health and Preventive Medicine, 26(1), 1-9.
  9. Patel, M. S., Volpp, K. G., Small, D. S., Wynne, C., Zhu, J., Yang, L., ... & Day, S. C. (2017). Using active choice within the electronic health record to increase influenza vaccination rates. Journal of general internal medicine, 32(7), 790-795.
  10. Tannenbaum, D., Doctor, J. N., Persell, S. D., Friedberg, M. W., Meeker, D., Friesema, E. M., ... & Fox, C. R. (2015). Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study. Journal of General Internal Medicine, 30(3), 298-304.
  11. Foster, M., Egerton-Warburton, D., Cullen, L., Fatovich, D. M., & Keijzers, G. (2021). Is a nudge all we need to promote deliberate clinical inertia and thoughtful clinical decision making?. Emergency Medicine Australasia, 33(4), 748-752.
About the Author

Laís Junqueira
Laís Junqueira is the Quality, Patient Safety and Innovation Manager at Elsevier. In this role, Laís provides strategic counsel to organizations on how evidence-based information and technology can improve patient safety and clinical outcomes and how Elsevier solutions can empower healthcare professionals on their path to deliver high quality and safer care through innovative solutions. Lais currently holds a position as a member of the Scientific Council and member of the Diversity and Inclusion Working Group of the Brazilian Society of Quality of Care and Patient Safety; Honorary member of the Patient Safety Foundation in Chile; is a Certified Six Sigma Black Belt and an associate member of the International Association of Innovation Professionals.

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