I need a 200-word reply to each of the following two forum post that were made by classmates in my business organization class. The post needs to be positive and not critical of the student.
Preventing mistakes is an important part of the quality process. In your opinion, what steps can be taken to reduce the chance of this happening again?
The stakes of a live show such as the Oscars is apparent after the Best Picture mix-up at this year’s show. Though I am not aware of the entire process that attempts to assure the accurate delivery of Oscars to appropriate winners, I do believe Pricewaterhouse Coopers could take some lessons from the healthcare industry to prevent a similar occurrence in the future.
In 1999, “the Institute of Medicine (IOM) released a report called: To err is human: Building a Safer Health System” (Kohn et al, 1999). The report focused on patient safety or more specifically, “the safety of care- defined as ‘freedom from accidental injury’.” (Hughes, 2008). Though the Oscars are not involved in life and death scenarios, I would argue that those involved in this year’s mix-up may have, at the time, felt differently. The health care industry utilizes many different techniques to prevent human error mistakes. Just to name a couple, I will discuss medication administration and surgical checklists. These tools albeit simple must be adhered rigorously to prevent err and reduce harm.
One example is the process followed prior to medication administration. Every nurse knows that you must establish the 5 rights prior to administration of any medication. These include the right patient, right medication, right dose, right route and right time. Another example borrowed from health care is surgical checklists that are tailored to the procedure. The checklist contains items as simple as the right patient, right (surgical) site, but also may include a “team time-out” when the entire surgical team stops to focus on the intended procedure. Other checklists function to remove hierarchies by having a checkpoint that any member of the team may halt the surgery without risk of retaliation.
Pricewaterhouse Coopers could develop a tailored process such as the “right award” of the “Oscar checklist” that reduces the chance of error. Perhaps a step in the right direction would be to eliminate the redundant award envelopes. Again, health care strives to reduce redundancies and hand-offs such as this to decrease the chance of human error. Couldn’t one argue that if there was not an extra envelope on one side of the stage, that envelope could not have been handed to the presenter to make the mistake? Doesn’t it seem easier to control the flow of presenters from one side of the stage rather than to produce a 2nd envelope?
Hughes, R. (2008). Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.
Kohn LT, Corrigan JM, Donaldson MS, editors. (1999). To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine.
As we know all too well, mistakes are a part of life itself. Preventing them is another. In my opinion there are steps that could be taken to reduce the chance of wrongfully presenting the Oscar again. It all begins with standard procedures and protocols. As Fritz, Rapoport, and Schwartzel (2017) noted, there are two personnel from the accounting firm on both sides of the stage holding identical envelopes because they are uncertain of where the presenters will enter the stage. I have never participated in something as publicly as the Oscars, however, I have participated in many ceremonies involving public audiences and awardees as part of my job in the military. The constant in every single awards ceremony is rehearsal. We also have certain procedures we are to follow in great detail (to include when and where to sit, when to stand, where to walk and face, and when and where to enter and exit the stage to name a few). With the understanding that these are hollywood celebrities, not accustmoed to such rigors a pre-ceremony rehearsals, to participate in such rehearsals would indeed give away the element of surprise as to who actually won each category. That would somehow put a damper on the entire experience.
Nonetheless, as there are various levels of seasoned celebrities involved that have been to these awards before and the fact that the same company and venue have been used over the past several decades, one would expect that a level of expectation would accompany the evening. The expectation that a speech would be given on stage after being announced the winner is not something that is rehearsed formally, it is just a tradition developed over the years. The same argument could be made in favor o the entire process if included. In fact, the producer of La La Land remarked that he had dreamed of standing on that stage, although he had never before done so (Fritz, Rappoport, & Schwartzel, 2017). This suggested that, although no person formally stated what to do or where, people just by witnessing over time learned the customs and traditional expectations.
Consequently, if the presenters and award winners were all required to enter and exit the stage at precise locations each time, the need for two identical suitcases with matching envelopes would not be needed. This would significantly reduce the risk associated with such an occurrence. Another factor would be to actually label the individual envelopes on the outside (if not already done so) in order to allow the card holder and the presenter an opportunity to validate they have the correct envelope. These processes have been around and in use within various healthcare organizations for years. The Joint Commissions frequently audits medical facilities to ensure they are in compliance with such regulations and practices like “Final timeout” used i surgeries nationwide. They use a process that verifies correct procedure, correct patient, and correct site prior to any surgery (The Joint Commission, n.d.). These procedures could also be adapted by the Academy and accounting firm entrusted with the integrity of the awards process. By having someone identified to direct the celebrities of when and where to go as presenters, the firm would be verifying that the correct procedures are being followed. By having only one suitcase of envelopes, the firm reduces the risk of not handing to the correct presenter (patient). Finally, by labeling the outside of the envelopes, the firm reduces th risk of not selecting the correct envelope (site). These simple procedural changes would certainly reduce the risks, if not eliminate them altogether.
The Joint Commissions. (n.d.). The universal protocol for preventing the wrong site, wrong procedure, and wrong person surgery. Speak Up. Retrieved from https://www.jointcommision.org/assets/1/18/Up_Poster.pdf
Fritz, B., Rapoport, M., and Schwartzel, E. (2017). PwC partner at Oscars tweeted backstage minutes before best picture mix-up. The Wall Street Journal. Retrieved from https://blackboard.uttyler.edu/bbcswebdav/pid-128869-dt-forum-rid-6425969_1/courses/2017-SPRING7WK2-MANA-5305.706/2017-SPRING7WK2-MANA-5305.706_ImportedContent_20170228121101/PwC%20Partner%20@%200scars%20Tweeted%20Backstage%20Minutes%20Before%20Best%20Picture%20Mix-Up%20-%20WSJ.pdf