It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.

What can a safety engineer learn from this 2017 Oscar fiasco?

I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.

Medicine also has “never events,” like wrong site surgery. Those events simply should not happen, but because humans are fallible, they do. Safety is no accident.

The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”

Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.

One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.

A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.

Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.

Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.

Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.

There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.

Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.

Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.

In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at .