By Evan M. Benjamin, MD
This month one of the biggest mistakes ever observed on live television occurred when Warren Beatty and Faye Dunaway, presenters of the Academy Award for Best Picture, announced the wrong film as the winner. Not since Janet Jackson’s wardrobe malfunction has live television caused such an 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?
Brian Cullinan, a PricewaterhouseCoopers (PwC) partner, had handed Warren Beatty the wrong envelope. Faye Dunaway, presenting the award with Mr. Beatty, read part of the card erroneously and 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, Mr. Cullinan had 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 the other partner, Martha L. Ruiz, 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 a photograph on Twitter that he had taken of Ms. Stone backstage, shortly after she won the award for Best Actress. Paying attention and 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 feature red paper with gold lettering that specified the award enclosed, rather than gold paper with dark lettering as in years past, making the new lettering harder to read. The design of the 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 he 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 they 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;” and “We need a second opinion” are escalating phrases you can use when there is uncertainty and concern.
So there is a lot we could learn from the Oscars blunder. Let’s keep seeing the issues and applying them to healthcare.
Evan M. Benjamin, MD is the senior vice president for quality and population health and chief quality officer at Baystate Health in Springfield, MA. He is also a professor of medicine at Tufts University. He can be reached at firstname.lastname@example.org.