What’s New in the Patient Safety World

April 2016

Nudge: An Example for Hand Hygiene



Our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” reviewed the book “Nudge” by Richard Thaler and Cass Sunstein. Yes, that’s the one that leads in with the story about how painting a picture of a fly in a male urinal resulted in 80% decreased spillage! The theme obviously is that small changes which cost little or nothing (i.e. nudges) can result in big impacts. The book is full of examples of how nudges can help steer people to make better choices in their personal life (savings, investments, healthcare, etc.) or from a societal perspective (improve the environment, improve organ donations, etc.).


In that 2009 column and in our February 18, 2014 Patient Safety Tip of the Week “Nudged, But Who Nudged Who?” we gave examples of how such small changes or “nudges” may lead to desirable changes in behavior in healthcare.


Hand hygiene is one area in which nudges may be helpful and that applies not only to healthcare personnel but also to visitors. A new study looked at factors related to use of alcohol-based hand sanitizers by visitors to a hospital (Hobbs 2016). The key finding was that when the hand sanitizers were placed in the middle of the lobby (with limited landmarks or barriers) visitors were 5.28 times more likely to use them. But the other key finding was that group behavior is important as well. In the Hobbs study individuals in a group were 39% more likely to use alcohol-based hand sanitizers. We’ve often viewed the same scenario with healthcare workers. A team in a teaching hospital (attending, several residents and students, and maybe a nurse or two) is doing rounds. If the attending stops to do hand hygiene before interacting with the patient, the whole team does hand hygiene. If he/she does not do hand hygiene, no one does. That’s a “nudge” that has a powerful impact.


So that addresses healthcare workers and visitors. What about patients themselves? After publication of a study last month (Cao 2016) we may need a “nudge” for them, too. Cao and colleagues did cultures of the hands of patients being admitted to post-acute care facilities from acute care hospitals. They found that 24.1% had at least one multidrug-resistant organism (MDRO) on their hands. Of course, other body parts may be colonized with hospital-acquired organisms but the patients’ hands are most likely to have been in contact with environmental surfaces, health care workers’ hands, or even other patients. Clearly, further studies need to be done to see how to intervene and prevent spread of such organisms in patients being discharged. Adding hand hygiene to patients being admitted to long-term care facilities would make sense. But adding hand hygiene to the discharge checklist of patients being discharged from acute care hospitals may make more sense since even those going home may be spreading MDRO’s. So a little “nudge” may be needed at discharge. Maybe putting another alcohol-based hand sanitizer in the lobby facing the other way will get both patients and visitors to perform hand hygiene on the way out, too!


“Nudges” do have positive impacts and we need to learn how to better deploy them.




Some of our other columns on hand hygiene:



January 5, 2010           How’s Your Hand Hygiene?

December 28, 2010     HAI’s: Looking In All The Wrong Places

May 24, 2011              Hand Hygiene Resources

October 2011              Another Unintended Consequence of Hand Hygiene Device?

March 2012                 Smile…You’re on Candid Camera

August 2012               Anesthesiology and Surgical Infections

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

November 18, 2014    Handwashing Fades at End of Shift, ?Smartwatch to the Rescue

January 20, 2015         He Didn’t Wash His Hands After What!

September 2015          APIC’s New Guide to Hand Hygiene Programs

November 2015          Hand Hygiene: Paradoxical Solution?







Thaler RH, Sunstein CR. Nudge. Improving Decisions about Health, Wealth, and Happiness. New Haven: Yale University Press, 2008




Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates.

Am J Infection Contol 2016; 44(3): 258-262




Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-Resistant Organisms on Patients’ Hands. A Missed Opportunity. JAMA Intern Med 2016; Published online March 14, 2016







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