Recently, one of the biggest mistakes ever observed on live television occurred when Warren Beatty and Faye Dunaway, presenters of the award, announced the wrong film as winner of the Academy Award for best picture. Not since Janet Jackson’s costume malfunction has, live television caused such uproar.
How could this have happened? How could it have been prevented? Moreover, what can this error teach us about how we care for patients?
A PricewaterhouseCoopers (PwC) partner had handed Warren Beatty the wrong envelope. Faye Dunaway, presenting the award with Mr. Beatty, reading part of the card erroneously announced that La La Land had won. Moments later, after accepting the award, the La La Land producers then announced that Moonlight was, in fact, the winner.
Instead of the envelope containing the winner for best picture, Brian Cullinan, a PwC partner, accidentally handed Mr. Beatty a duplicate of the envelope for best actress — an award Emma Stone had accepted for her role in La La Land just moments before.
Let’s think about what happened from the perspective of safety and reliability.
Process design. For the Oscars, PwC uses two complete sets of the envelopes, with one placed on each side of the stage. Mr. Cullinan was handling one side, and another PwC partner was handling the other. Having two sets of envelopes instead of one created convenience but immediately lowered reliability and created room for error. Extra work had to be done by both partners on either side to track which envelope was to be used next. Using principles of reliability to simplify processes and have one consistent approach is key to good process design.
Distraction. It isn’t clear what led Mr. Cullinan to hand Mr. Beatty the wrong envelope, but distraction may have played a role. Just moments before he handed the envelope to Mr. Beatty, Mr. Cullinan posted on Twitter a photograph he took of Ms. Stone backstage shortly after she won the award for best actress. Paying attention, staying in the moment at the task at hand is critical to safety and reliability.
Tool design. The design of the envelopes could have been a factor. The envelopes were redesigned this year to withred paper with gold lettering that indicated the award enclosed, rather than gold paper with dark lettering as in years past making the new lettering harder to read. The design of tools we use plays a critical role in the reliability of care.
Error identification. Warren Beatty was clearly confused when he opened the envelope. He was the last slice of cheese in Reason’s Swiss Cheese Model to catch the error from impacting 30 million viewers. He delayed announcing the winner as he saw the name “Emma Stone” rather than the name of a film as he expected. Instead of stopping and asking for help, his first reaction was “I must be wrong” and did not call out for clarification. Usually, when one is confused, it is a sign that something, someone, or the system is failing you. Pause. Take a time out.
Diffusion of responsibility. Faye Dunaway thought Beatty was being coy with his delay and encouraged him to read the winner. Feeling pressured, Beatty then handed the confusing card to Dunaway who saw “La La Land” (ignoring the name Emma Stone) and proclaimed it the winner. Our research has shown that sometimes in teams one assumes the other person knows what is best even though you are questioning the decision. This is the time to “call out” for safety.
How can you voice your concern?
When there is confusion, voice your concern using critical language to let others know you are unsure. “I am concerned”; “I am uncomfortable”; “I have a safety concern”; “We need a second opinion” are escalating phrases one can use when there is uncertainly and concern.
So there is a lot we could learn from the Oscar blunder. Let’s keep seeing the issues and applying them to health care.
Evan M. Benjamin is chief quality officer, Baystate Health, Springfield, MA.
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