To bring this process completely into perspective, let’s consider the snafu that capped the night of the 2017 Academy Awards presentation – the mistaken announcement that La La Land had won the Oscar for best picture, only to be reversed moments later by the declaration that Moonlight was the true winner. Most certainly, this on-stage blunder failed to meet an acceptable standard of performance.
Sometimes Never Events are simply the product of one person’s egregiously bad behavior. More often, however, they are the result of a coincidental series of unfortunate events. In the Academy Award snafu, for example, several factors lined up, like the holes in Swiss cheese, to produce this calamitous outcome. An RCA would likely have concluded this was a system problem.
First, a crucial contributor to the error was the existence of duplicate copies of every award envelope. This paved the way for one envelope (in this case, the Best Actress award) to be substituted for another, virtually identical, envelope (the Best Picture Award), much like two medications with similar names or appearances being mistaken for each other.
Second, the envelopes were not well marked. A new vendor for design of the envelopes had reportedly changed the colors, contrast, and font size of the envelope labels, making them more attractive but also more difficult to read in the muted lighting behind the stage curtains, permitting the PricewaterhouseCoopers (PwC) representative to select the wrong envelope.
Third, the cards themselves were not designed for clarity, so the duplicate card could not be easily identified as such. While the uninformative label, “OSCARS,” enjoyed marquee billing at the top, and the movie title and actor credit were prominently displayed in the center, the all-important category of the award, “Best Actress,” was barely visible in a tiny font at the bottom. As is usually the case, it is easy to see the design flaw through the perfect lens of the retrospectoscope.
From The Ailing Nation, Chapter Two: Forgiveness
No one wants to make a mistake. Not even a tiny one that no one notices. And certainly not a giant blunder that is witnessed by millions. The snafu of the 2017 Academy Awards was notable for its scope and notoriety. In my hospital, we would call an error of this magnitude a Never Event, the equivalent of operating on the wrong patient or amputating the wrong leg. Never Events are especially bad outcomes that must never be allowed to happen. Given their extreme severity, they require a systematic approach with multiple layers of protection to prevent their occurrence. Never Events usually turn out to be facilitated by a coincidental series of unfortunate mishaps, just like the missed call at the Oscars. The goal of the investigation is to uncover all those tiny steps that led to the outcome, and come up with a remedy for each one. To be sure, it is always easier to find mistakes looking behind us in our past then ahead of us in our future. The retrospectoscope, after all, has a lens with perfect clarity.
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