Relying on Memory Leads to Rework
On Tuesday, Chief Justice John Roberts appeared to flub his giving of the presidential oath of office, leaving out the word “faithfully” in the phrase “I will faithfully execute the office….” Roberts said “I will execute the office of President to the United States…” and then, in his second attempt, tacked on “faithfully” at the end of the phrase. I'm pretty sure “President to the United states” was wrong too.
That's a pretty big stage upon which to have a “defect” in the process. Somewhat spoiled a historic moment.
The cause of the error? Roberts chose not to use a notecard or a “checklist.” Is it confidence or arrogance to think, “I can memorize these 35 words” and not have a notecard as a backup if you get nervous or forgetful?
…the Supreme Court chief, who a day earlier had to recite to Obama the 35-word oath of office, which Obama was to repeat back to him. Unlike his predecessor, Chief Justice William Rehnquist, Roberts — perhaps unwisely — chose to forego a note card with the oath.
When he started to say the second portion of the quote “… that I will faithfully execute the office of president of the United States,” he instead put faithfully at the end of the sentence. Obama, who apparently had memorized the oath, looked at Roberts, who then realized his mistake and repeated that portion of the oath correctly.
Because there was some confusion about the legality of the oath having been said incorrectly (President Obama repeated the defective oath as read by Roberts), the oath was re-administered.
I think we have our first case of “inaugural rework” here? It certainly wasn't “done right the first time” as we would say in the Lean world.
It's ironic that the failure to use a checklist tarnished the inauguration when, last week, the issue of surgical checklists made such big news. I will blog about that topic more, but it seems to tie into what happened Tuesday.
New research published today in the New England Journal of Medicine found that when surgical teams heeded a simple checklist â€” as pilots do before takeoff â€” patient-mortality rates were cut nearly in half and complications fell by more than a third.
The study â€” which included 7,688 patients in eight hospitals around the world â€” saw death rates drop from 1.5% before the checklist was instituted to 0.8% afterward. Serious complications fell from 11% to 7%. Study sites included Seattle, London, Toronto, New Delhi, and Ifakara, Tanzania.
One major advantage of a checklist is that it makes it harder (or impossible) to “forget” a step in a process or to do steps in the wrong order. Some people get overconfident (or maybe cocky) and think “well I couldn't possibly make that mistake, I'm smarter than that” and they don't want to use the checklist.
We need people in healthcare to take an oath maybe….
“I will execute this checklist to the surgical process…. faithfully.”
or “I will faithfully execute the checklists….” Either way :-)