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Mark Graban

Quality Insider

World Series Defect: Wrong Pitcher

Lessons learned from a very public error

Published: Tuesday, November 1, 2011 - 14:46

People in health care know that miscommunications are a major cause of errors and potential harm. A curious incident that occurred during game five of the 2011 World Series illustrated this issue in a very public way: A miscommunication set off an action that ultimately left the St. Louis Cardinals and their (now retired) manager, Tony La Russa, without the right pitcher for a relief appearance during the eighth inning. As a result, the Texas Rangers beat the Cardinals 4–2.

Although the Cardinals ultimately went on to win the series, the communication glitch meant that the team faced a furious battle for the remaining two games. This was exciting for the fans, but obviously nerve-wracking for La Russa and his team.

What happened?

“St. Louis Cardinals Manager Tony La Russa says a bullpen miscommunication resulted in his inability to use closer Jason Motte in Game 5 of the World Series,” announced UPI.com on Oct. 25, 2011, a day after the incident.

Because the Texas Rangers stadium was loud, La Russa had trouble communicating over the “bullpen phone” that’s used to call from the dugout to the place where pitchers are sitting and waiting to get ready to come into the game.

La Russa called and wanted two pitchers to warm up to possibly get into the game—Marc Rzepczynski and Jason Motte. But instead, the bullpen had only Rzepczynski warm up. Rzepczynski was brought into the game, but then La Russa wanted to bring in Motte.

“They [the bullpen] didn’t hear ‘Motte,’ and when I looked up there, Motte wasn’t going,” La Russa told the St. Louis Post-Dispatch.

Since Motte, arguably their best relief pitcher, wasn’t available, La Russa had to leave Rzepczynski in the game, and he promptly gave up what ended up being the game-winning hit to the Rangers’ Mike Napoli.

An ESPN report said that the Rangers’ crowd was the loudest it had ever been, making it harder to hear than usual. This helps illustrate the weakness of verbal communications and the errors that can result—in health care or baseball. I guess the bullpen didn’t do a verbal read back of the order from La Russa.

ESPN also reported that, due to the physical layout of the Rangers’ ballpark, the visiting manager (in this case, La Russa) can’t really see the bullpen from the dugout. He couldn’t see there was only one pitcher getting ready instead of two. This helps illustrate the need for visual management in any workplace and layouts that provide good visibility to the work that’s being managed.

As great leaders tend to do, La Russa took the blame himself instead of throwing a subordinate under the bus, saying, “You go and make a pitching change, [and] you’ve got the wrong guy coming out there, that’s not fun. Geez, that was embarrassing.”

“He reiterated the notion that he had intended to have closer Jason Motte warming up alongside Rzepczynski, in order to be ready to face Napoli, but that half of the request was never heard by bullpen coach Derek Lilliquist—with La Russa suggesting (for the first time) that he spoke Motte’s name too late, after Lilliquist had hung up,” reported Dave Sheinin in The Washington Post.

“He felt bad about it,” La Russa said of Lilliquist, “but I said, ‘Hey, that’s my fault.’”

There’s one other aspect of the story that might remind people of other situations where errors occur: People working for La Russa didn’t speak up about the possible error. This is one of the lessons from improvements in patient safety, and also illustrated in naval situations, where crew members—including the first officer—need to be able to speak up when they think the commanding officer is possibly making a mistake.

ESPN reported that Motte, the team’s “closer,” didn’t speak up or question anything, when he likely should have asked why he wasn’t being warmed up. Why didn’t Lilliquist question La Russa? Possibly because La Russa has decades of managing experience and is considered one of the best in the game.

How many other times is a person afraid to challenge a high-ranking officer who has a great track record? It’s amazing how these lessons can be so effectively demonstrated in something like a ballgame, isn’t it?

Is it surprising that baseball teams rely on verbal communication? Why not text message? Why not “manager reliever order entry” computer systems, like CPOE in health care? La Russa blames himself, but is there a way they can fix the process for the future? How can you error-proof that communication?

“We don’t have a procedure where you say this and the guy says, ‘roger,’” La Russa was quoted in a Los Angeles Times report. “If the guy can’t hear, sometimes he says it.”

Didn’t have a procedure… or at least they didn’t have consistently executed standardized work, as we’d say in lean.

Then, according to the Los Angeles Times story, there was a second communication error in that same inning:

“With Napoli at the plate, La Russa called the bullpen a second time, again ordering Motte to get ready. And again Lilliquist apparently misunderstood, handing the ball to a surprised Lance Lynn, who had thrown 47 pitches the game before and was supposed to have the night off.

“Maybe I slurred it,” La Russa said about the second call for Motte. As for why Lilliquist didn’t question the request for Lynn to get warmed up in the bullpen, given his off-limits status, La Russa said, “I would be disappointed if Derek [had said], ‘Tony, I mean, do you know what you’re doing?’”

So a batter later, when the manager went to the mound and waved in a reliever, it was Lynn who jogged in from the bullpen.

“I saw Lynn. I went, ‘Oh, what are you doing here?’” La Russa said.

Why does the “call to the bullpen” have to be a phone call? Maybe this applies to just the past few decades, but is it a case of “we’ve always done it that way?”


About The Author

Mark Graban’s picture

Mark Graban

Mark Graban is an author, educator, and speaker in lean health care, through his company Constancy Inc. He is a faculty member for the Lean Enterprise Institute (LEI) and vice president of improvement and innovation services at KaiNexus, a technology company that helps organizations spread continuous improvement. He is founder of the Lean Blog and is author of Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition (Productivity Press, 2011) and, with Joseph E. Swartz, Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements (Productivity Press, 2012), both recipients of the Shingo Professional Publication and Research Award.