(First published 27 March, 2017)
Things were smooth-sailing during this year’s 89th Academy Awards, until the famous Oscar gaffe occurred where Warren Beatty and Faye Dunaway announced the wrong Best Picture. In the wake of the mess, Beatty tried to clarify on stage how he saw the winner card in his hand was for Best Actress, had Emma Stone's name on it, as well as the movie that represented her work, La La Land.
Beatty knew the card was wrong, fidgeted in a way that was misperceived as “dramatic suspense”, and in the midst of his confusion presented the card to his co-presenter Dunaway. Naturally, with all that anticipation, Dunaway knew all she needed was to scan the card for one of 9 movie titles, and read out that one movie title that appeared on the card. The Best Picture award was meant for the movie Moonlight, but Dunaway said La La Land. In the words of Jimmy Kimmel, "Clyde threw Bonnie under the bus". The damage was done.
There were parallels between this 2017 Oscar mix-up and the 2015 Miss Universe Pageant in which show presenter Steve Harvey misread the winner card, resulting in the crowning of Miss Colombia instead of the actual winner, Miss Philippines. Both instances hinted of flawed card designs: key information insufficiently salient, confusing or redundant features, unintuitive layout etc.
Other human factors issues include a lapse in the complicated process of distributing winner cards, as well as our natural tendency to see what we expect to see. A system was in place to provide celebrity presenters entering from either side of the stage with their corresponding announcement cards. This meant that there were two sets of the same cards, and when one card was issued, the duplicate card at the other side of the stage should be discarded. Evidently this manual process somehow failed, and the embarrassed auditing firm responsible for this apologized.
Their subsequent mitigating strategy is to introduce a third guy with a third set of envelopes, and this third guy has to commit all the award winners to memory.
With all that anticipation and urgency, Dunaway, expecting it to be the correct card and expecting to read out whatever movie title that appeared on that card, promptly scanned and read out whatever movie title that she saw. She did her job, but one could say she was set up to fail.
Ironically, the mistake was actually noticed and could have been completely prevented. Had Beatty said “I think this is the wrong card” audible enough for Dunaway or anyone backstage, somebody could have at least acted. The wrong movie production team subsequently would not have been called on stage, briefly acknowledged a trophy that was not theirs, only to awkwardly make their way back off.
This Oscar incident presented many issues which are similar in patient safety. Many lookalikes exist throughout the system, from drugs to names to even babies. Procedures are highly manual and prone to human error. When the system is poorly-designed, we too are set up to fail, or at least hinder us from working efficiently.
More importantly, don't give error the chance to occur. If something appears wrong or confusing, don't wait, don't keep it to yourself, speak up for safety.
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