Patient Safety Lessons from the LaLa Envelope Gate Incident.

Many of us watched live the 2017 academy awards along with 33 million other people as Warren Beatty stood next to Faye Dunaway on stage performing a seemingly simple task; open an envelope and announce the Oscar for category of Best Picture. Warren Beatie opens the red envelope handed to her, takes a long look and pauses. If you look back at the footage Warren knows something is wrong, Faye thinks he is trying to be funny looks at the card and announces the best picture as “La La Land” and the audience erupts into applause. Accountant Brian Cullinan (PWC), the man responsible for handing the envelop, knows a screw up is in full swing and the correct winner is in fact Moon Light, and not La La Land. He realised he had handed the incorrect envelop and decided to intervene. Jimmy Kimmel the MC immediately took to blame Warren when the announcement was made by Faye. This is a typical response when error is identified - our first instinct is to blame the operator. Many quickly moved on to blamed the accountant who was responsible for handing the wrong envelope.

Neither Warren Beatty nor Faye Dunaway was at fault, most people went on blame the accountant Brian Cullen but it’s important to realise that he cannot be blamed either. Put simply, the Oscars Academy system had failed, leading to the iconic debacle. ?

It would be a mistake to blame Cullinan as he is only Human, and to err is human. Humans are always at risk of being distracted which often leads to avoidable mistakes. We cannot demand better humans; however, we can certainly demand better systems to mitigate the problem.

The Oscars system’s failure resulted in some embarrassment to certain high-profile celebrities but thankfully did not result in any loss of life. The same cannot be said for a systems failure in Healthcare where the stakes are much higher.

Lessons from the fiasco are far from trivial; the same kind of mistake in different circumstances can lead to catastrophic consequences such as patient care, leading to serious incidents. Let’s try to put that into perspective by looking at the events from that night:

1.??????Distractions - Cullinan was on the phone.

2.??????Bad typography in identifying the correct information. Large print showing redundant information, had the card read “Best Actress: Emma Stone” in larger text, Warren may have noticed he had been given the incorrect card. Better design prevents operator error. Benjamin Bannister on?typography at the Oscars

3.??????Complexity - handing out an envelope should be a simple process. Galileo’s Warning essentially states that a precautionary measure turns out to be a potential cause of disaster, Galileo tried to teach us that when we add more and more layers to a system intended to avert disaster, those layers of complexity may eventually be what causes the catastrophe. His case study relates to the storage of stone construction pillars, instead of having two supports at either end, an engineer adds a central support to pillars, which becomes a pivot over time and causes the very incident they were looking to prevent. Adding protective steps can lead to the same error we are trying to prevent. Galileo’s?Dialogues Concerning Two New Sciences. The academy in an effort to create a fool proof system introduced unnecessary redundancy through a twin card system which attempts to reduce chances of error by having two operators handle the envelopes and discard them in sync.

4.??????Vulnerable systems have two things in common: they are tightly coupled and complex. With every additional preventative step, additional complexity is added to the process and that increases the chances of errors. BBC’s?Truth Behind Envelopgate

I was motivated to write this post not as a NHS Non Executive sitting on Quality Improvement or Patient Safety groups but during a group discussion with the highly engaging Vascular Surgeon Perbinder Grewal. While teaching his Human Factors & Patient Safety course, he found that many healthcare professional see safety through a clinical lens only. Many believe problems are unique to healthcare when many of the same concerns have already been addressed through application of good process design and systems engineering approach within safety critical sectors such aviation and nuclear power.

A large part of medication errors are due to operator distraction and red tabards are not the complete solution. Process controls such as coding and positive patient identification taking place at the point of dispensing help prevent misidentification and inaccurate dispensing of medications.

Adding unnecessary precautionary steps can lead to fatal consequence. Perbinder relates an incident at Vanderbilt University Hospital, Tennessee, of a patient presenting with a subdural hematoma having recovered ready for discharge, when the clinician requests a final scan. During a final scan in the hospital’s radiology department, patient is supposed to be given a sedative, Versed (Midazolam), but is accidentally given a dose of vecuronium, a powerful paralyzing medication, according to a federal investigations report. The drug leaves her?brain dead.

Clinician often under estimate the power of a white coat patients are known to consent to unnecessary procedures if suggested by a doctor. Many examples of closely coupled risks are seen when patients’ files missidentified at primary care lead to patients consenting to surgery for a procedure(s) they did not need.

Much can be learned by healthcare by adopting a safe system approach to better patient safety, learning from other sectors; aviation, nuclear and construction engineering. We must view #PSIRF as a necessary step along a journey.

Healthcare language itself can be a barrier to better safety culture we speak of “Never Events” and “Avoidable Deaths” by implication someone at fault!?

Perbinder Singh Grewal #patientsafety #healthcare #iboxhealthcare #6ghi #epr #healthtech #nhs #patientexperience #learning #culture