World Series Defect: Wrong Pitcher


People in healthcare know that miscommunications are a major cause of errors and patient harm. There was a strange footnote to game 5 of the World Series, where the Texas Rangers beat the St. Louis Cardinals 4-2. A miscommunication led to the Cardinals and their manager, Tony LaRussa, not having the right pitcher available for a relief appearance in the 8th inning.

What happened?

From a news report:

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.

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, for those of you unfamiliar with baseball, the place there pitchers are sitting and waiting to get ready to come into the game.

LaRussa called and wanted two pitchers to warm up to possibly get into the game – Marc Rzepcynski and Jason Motte. But, instead, the bullpen only had Rzepcynski warm up. Rzepcynski was brought into the game, but then LaRussa 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, LaRussa 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 healthcare or baseball. I guess the bullpen didn't do a verbal read back of the order from LaRussa.

ESPN also reported that, due to the physical layout of the Rangers' ballpark, the visiting manager (in this case LaRussa) 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, LaRussa 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.”

From the news report:

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.

“He felt bad about it,” La Russa said of Lillquist, “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 – the people working for LaRussa didn't speak up about the possible error. This is one of the lessons from the improvements in patient safety, that crew members (including the first officer) need to be able to speak up when they think the commanding officer is possibly making a mistake (see “crew resource management“).

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

“Maybe I slurred it,” La Russa said of the second call for Motte. As for why Lilliquist didn't question the request for Lynn to get warm 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?' “

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 illustrated 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 healthcare? LaRussa blames himself, but is there a way they can fix the process for the future? How can you error proof that communication?

From another article, LaRussa commented:

“We don't have a procedure where you say this and the guy says ‘Roger,' ” La Russa said. “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 would say in Lean.

Then, 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.

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?”

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. In the spirit of continuous improvement, did you intentionally verbify a noun Mark? “you can also quality to win”

    Regarding the sports analogy, I think your final observation of ‘we’ve always done it this way’ hits the mark. A process map of the game decision points involves more than just the pitcher foul up and includes hitters not hitting (esp. with runners on base–JIT?) and there appears to be a trend there in all of the losses.

  2. Excellent article. I think the lessons here tie directly to common hospital problems as you have pointed out, especially the call-back/repeat-back element. I have heard of many cases where a call-back has saved patients from harm. Maybe major league sports is the next frontier for Lean folks!

  3. Healthcare story at AME today – hospital started having patients do a “teach back” to the nurses (in a separate session) so they could confirm that the patients have really understood their discharge education. Previously, “the nurses just assumed” the patients understood.

    Reminds me of the old Training Within Industry principle – if the student hasn’t learned, then the teacher hasn’t taught.

    • It’s right out of basic communications training, too – validate understanding by repeating back. Active listening, as I learned it once.

      Like so much else, it’s so well known and understood that nobody bothers to do it!

  4. Great illustration of the importance of visual management, SOPs, checking, andon / stop-and-call and so much more. Well done Mark.

    One would think sports teams would do FMEAs against this sort of thing, especially when the stakes are the World Series.

  5. Guess we are lucky here in New Zealand that the All Blacks didn’t have similair problems during their World Cup Finals game against France

  6. As a former worker in the St. Louis farm system, a lifelong baseball lover and an expert in workplace communication, I was horrified when I heard about these two communication mishaps. (I wasn’t able to watch the game.) Why not use texting? Why not repeat orders if nby verbal? Why not challenge LaRussa? So many errors, which are great learning opportunities for everyone else. I agree that LaRussa’s post-game behavior of taking responsibility was admirable. And as a former official scorekeeper (for my high school baseball team), I rue the fact that these errors weren’t captured officially.

  7. There was a similar “wrong pitcher” situation this week with a different failure mode.


    The interim manager, Robby Thompson, came out to the mound and wanted to bring in a right handed pitcher. He accidentally raised his left arm a bit and immediately corrected himself.

    But umpires forced him to bring in the lefty.

    That seems pretty stupid that the umpires wouldn’t allow him to correct his “wrong arm” error. It’s not like correcting the error would have given him an unfair advantage. The wrong pitcher wasn’t yet running out to the mound.

    The Red Sox manager said he wouldn’t have argued against allowing the righty into the game.

    I bet the umpires were on a power trip instead of doing what seemed reasonable.


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