I’ll apologize in advance to those of you who don’t care about football. Thursday night, we saw the type of error that happens every few years in the NFL… a player, Danny Trevathan, of the Denver Broncos, was about to score an easy touchdown, yet he dropped the ball, celebrating early, before crossing “the plane” of the end zone.
It might seem like a silly rule, but a rule is a rule, so the play was ruled a touchback – zero points for the Broncos and the ball went back to the Ravens. It didn’t cost the Broncos the game, but it’s worth looking at a little more closely.
Here is an animated GIF of the mishap, where he drops the ball at about the 1-yard line) or see video here.
The NFL rules say you have to carry the ball across the end zone line. Once you cross the plane, you can drop it, spike it, “dunk” it over the goalposts, hand it to a ref, or throw it into the stands (although that draws a fine).
Trevathan, as a linebacker, probably hasn’t scored too many touchdowns in his life. So, arguably, he doesn’t have much practice.
That said, he’s probably well aware of the rule and just had a brain cramp. He knows you have the carry the ball across and just messed up in the moment.
“It was a young mistake. I was just in the moment,” Trevathan told reporters after the game, per the Broncos‘ official website. “I thought I was in the end zone. Next time I’m going (to) hold the ball up high and give it to a fan or something. But it’s not going to happen again. I’m growing from it and I’m not … going to let anybody stop me.”
Of course he thought he was in the end zone. I guess he’s learned a lesson that the safest thing is to BE SURE that he’s in the end zone. Barry Sanders, an NFL great running back, just flipped or handed the ball to the official instead of showboating or celebrating too much.
Friday night, my wife and I were going to have sushi delivered from a local restaurant. It was the first time I had used the restaurant’s website and the interface was a bit clunky. I managed to place the order as “pick up” instead of “delivery,” as I had intended.
Now, this was totally my fault, as I should have looked closely at the confirmation email that arrived. It was only when I thought the delivery was late that I re-opened the email and realized I had screwed up.
As with many mistakes (like booking a flight for the wrong date), it’s the type of mistake you tend to make just once. But, you’re not the only one who has ever made that mistake (nor is Danny Trevathan – the Eagles’ DeSean Jackson did it a few years ago).
I guess if Trevathan was a marginal player and that mistake had cost the Broncos the game, the worst that might have happened was him being cut by the team.
We see many situations in hospitals where people make a mistake or a slip up… and we often see situations where:
- People know the rules (or the process or the standardized work)
- They don’t mean to make a mistake, but sometimes a mistake is made in the heat of the moment
When mistakes happen in hospitals (like cutting into the wrong side of a patient), we don’t have video to analyze over and over. There are also generally procedures and protocols in hospital operating rooms that are meant to prevent these slip ups (but the checklists and “universal protocols” are sometimes not followed).
The Broncos wouldn’t solve this problem by hanging big warning signs that say “DON’T FORGET TO CARRY THE BALL TO THE BACK LINE OF THE END ZONE” or such. They will probably address this in team meetings to make sure every player is more aware of the rules.
I’d also predict that EVERY NFL TEAM talked about this in team meetings on Friday.
When a mistake or slip up happens in a hospital, does every other hospital review the mistake so they can avoid making the same error themselves?
Does your healthcare team talk about things that COULD go wrong? Do you talk about errors and mishaps from other hospitals that are in the news? Do you proactively talk about how you can prevent these same errors or do you assume your people will always carry the ball the whole way into the end zone?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.