Table 3.

Representative Quotes: Behavioral Economics Determinants of Blood Culture Overuse

Cognitive bias	Representative quote	Participant type and site
Outcome bias(allowing a prior event or decision outcome to influence subsequent independent decisions)	“I do think that those cases, those mortalities have been crucial in my understanding that you have to be more aggressive at the beginning.” Fellow, low performing site (2)“If I recently had like a bad experience where that happened, then it’s possible that I would be more likely to get cultures sooner.” Physician’s Assistant, high performing site (4)“I think [I would have] a lot of guilt, honestly, because that was a decision on my part to just watch in six hours when it comes to bacteremia and sepsis is a big deal and I don’t think it’s something that I would just be able to roll-off, and I think it’d be something that I would take with me going forward as a clinician with other patients I encounter who become febrile. I think it would probably impact the way I go about treating all other patients and I would probably just be a little bit more fearful and not as confident.”	Fellow, low performing site (2)Physician’s Assistant, high performing site (4)Resident, high performing site (6)
Default bias(the tendency to continue the status quo)	“I came from an institution where at least initially, in many cases, if a patient had a fever, the immediate knee-jerk response was to get a blood culture from a central line if they had it.”“I mean, pretty much in our unit if you have a fever, you’re going to get a blood culture.”“We watch the culture for 48 hours, keep them on antibiotics…. We stop thinking about it.”	Attending physician, high performing site (3)Nurse, low performing site (1)Attending physician, low performing site (2)
Loss aversion(the notion that preventing a loss is more important than a corresponding potential gain)	Interviewer: How can you think about the risks versus benefits of obtaining a blood culture in the PICU patient? Interviewee: “I think there’s almost no risk of getting it besides worsening the amount of anemia that the patient can get in the ICU, but all those things are in theory reversible, right. So, I think it’s a minimal risk to get it and then there’s more benefit as long as you have a strong feeling that the patient may be bacteremic….you have to rule out that a patient may be becteremic.”“Because it’s [sepsis] just something that you definitely you don’t want to miss and it’s easy enough to draw the culture, and put them on antibiotics.”	Fellow, low performing site (2)Attending physician, low performing site (2)