It was the most dramatic moment in the history of the Academy Awards. And if you didn’t watch the 2017 Oscars ceremony, you will certainly have heard about it. The film La La Land was announced as the winner of Best Film, but then had to hand the award over to Moonlight after a mistake was noticed in what was described as the most embarrassing moment in the 80-year history of the Academy Awards.

PriceWaterhouseCoopers, the accountancy firm that has overseen the counting of the Oscars votes for 83 years, apologised for the error and promised an investigation. In a statement, it said, “The presenters had mistakenly been given the wrong category envelope and when discovered, was immediately corrected. We are currently investigating how this could have happened, and deeply regret that this occurred. We appreciate the grace with which the nominees, the Academy, ABC and [host] Jimmy Kimmel handled the situation.”

Such a mistake – being given the wrong seemingly identical envelope in an ordinary setting – is usually uneventful. Similar things happen every day. The only thing that is incredible, spectacular and extraordinary is the context. Apply a similar simple mistake to pharmacy and the dispensing process, and it provides an interesting vignette with which to introduce the importance of human factors and their contribution to errors.

Even the most capable pharmacist, technician or pharmacy team member has the potential to make potentially harmful mistakes, as all humans are fallible. Having robust systems in place to both detect errors quickly and to prevent them recurring is key to a safer working environment. Ideas to help reduce the risk of errors in community pharmacy include regular patient safety briefings for teams to help firmly establish a safety culture.