Small Steps to Big Problems: Lessons from the Oscars to the OR

Even if you did not stay up past midnight on a Sunday in February to find out who won best picture at the Academy Awards, you surely heard or read about it the next day.

Compared to the life and death situations that occur daily in healthcare provider organizations, a group of actors and other Hollywood royalty in muddled confusion on stage before millions of television viewers falls short of a disaster. But, from the perspective of the show’s producers, fumbling the biggest award of the night – in slow motion – was about as bad as it could get.

As with all high-profile mishaps, the finger-pointing started quickly and everyone was looking for the fall guy, that single human or technical error that caused the whole debacle. But, as was methodically explained by author James Megis in his article “How Disaster Science Explains the Oscars Mix-Up,” it was a series of minor events that led to a major mistake. And, while the context and consequences are starkly different, the types of mistakes and how to avoid them have parallels in healthcare.

  1. Because PWC takes great pride in its job of tallying and safeguarding the Oscar winners, two senior partners personally hand the envelopes to the award presenters. But “many accidents have been triggered by very experienced workers who grew over-confident and complacent.” This is true in medicine as well. Any individual – from a pharmacy tech to a surgeon – can become complacent when performing similar tasks again and again. Processes and safeguards must be reviewed and refreshed regularly and, even more important, a culture in which all employees feel comfortable speaking up and pointing out potential dangers must be established. Sometimes a pair of fresh, less experienced eyes will spot something that a veteran expert will miss.
  2. The only two people, in the entire world, who knew who the true winner of the best picture award was supposed to be were the PWC partners. This was great for security, but terrible for rapid response to the error because “it was impossible for the show’s director or anyone else to know immediately that a mistake had been made.” You have to trust your people. If they don’t know the plan, they cannot realize that something has gone awry and move to minimize the damage. And they certainly cannot anticipate and prevent circumstances that might derail the plan before they occur.
  3. Each of the two PWC partners had a full set of envelopes containing the names of winners in all categories. One partner stood stage left and the other stage right with duplicate piles of envelopes. They did this just in case a presenter went off-script and entered from the wrong side of the stage. So, a measure intended to prevent a small mishap, such as a few seconds lost while the presenter is directed to the correct (and rehearsed) side of the stage, becomes a BIG mistake because one PWC partner was still holding two envelopes when there was only one award left. In healthcare, we have to be ready for contingencies and often need to revert to plan B, C, and so on. But there is a difference between being prepared and bogging down the process with unnecessary precautions. Clearly, evaluating and streamlining processes is one lesson. The bigger one, again, is trust. Collective focus on the objective and a true spirit of collaboration will yield a better response to almost any unexpected situation when you have properly trained people in whom you can trust.
  4. Even when it was clear, no one wanted to acknowledge that something was wrong. Warren Beatty realized that he was not seeing exactly what he should have been when he opened the envelope, but he hesitated. Faye Dunaway “zeroed in on the words she expected to see, La La Land,” and blocked out the words he was not expecting – the name of the actress who had just won for her role in La La Land. And when Ms. Dunaway announced the wrong winner, the PWC executives, who knew immediately that it was a mistake, took more than a minute to alert the stage manager. This scenario applies to healthcare at the highest level. How long was it clear to clinicians and administrators across the industry that something was wrong before we began to acknowledge and address it? I see this within organizations all the time as well. “We have known for some time that we had a problem,” or “I have been frustrated with this process for years” are common remarks. The lesson here is this: Hesitate at your peril. A small problem will become big very quickly and those who take a wait-and-see approach will likely see their own demise.

You can read the full text of “How Disaster Science Explains the Oscar Mix Up” here.

For more information about how to build trust and competence in your organization, please contact Mo Kasti at 813-333-1401 or

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