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.

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