Or, why didn’t Beatty “stop the line”?

How could La La Land get called, when Moonlight had won? I mean, it’s not hard! Count the votes, put the result in an envelope, and hand it to Warren Beatty. Surely a “never event”.

But how do operations get done on the wrong patient, or on the wrong side? How do swabs get left behind? That’s not hard either.

It’s not that the Oscar organisers are slapdash; more interested in getting the red carpet just so. They fret mightily over envelope checking. Instead of putting them on the rostrum for Beatty to pick up, they pay someone to hand them to him. In fact they pay two people, one each side of the stage, each with duplicate sets, to ensure the show runs smoothly. I bet they had rehearsals and procedures. But still Beatty got the wrong envelope.

It’s easy to guess why. At the critical moment someone distracted the envelope carrier; perhaps he had to restrain a previous winner from rushing back to thank his mum. Whatever the cause, he failed to do one simple task, remove the spare envelope.

The situation could still have been saved. Beatty realised he’d got the wrong envelope, “Best actress” instead of “Best picture”. But instead of stepping back to check, he handed it to Faye Dunaway anyway. She, caught up in the moment, ploughed on and announced the wrong winner.

Why didn’t Beatty “stop the line” for Oscar safety? Why don’t nurses “stop the line” for patient safety? Perhaps he thought it was a stunt, or he didn’t want to slow the show; it was running late, just like operating lists sometimes do. Whatever the reason, the wrong film got the Oscar, and “never events” happen. Three lessons I guess.

1. Don’t over complicate. One set of envelopes, or one patient ID wristband, is plenty.
2. Don’t distract people doing the checks.
3. Teach everyone, from theatre orderlies to Warren Beatty, it’s OK to “stop the line”.

But “never events” won’t disappear. They don’t matter in Hollywood, but they do in hospital. So do you really need that operation? Will it do enough good to balance the risk of the surgeon maiming you by some simple, stupid, “never event”? Think about it.

Jim Thornton