I remember watching this game live on TV, and I can’t believe this mistake happened 25 years ago now!

From The Athletic:

The Lions, the Steelers and a crazy, botched Thanksgiving coin flip 25 years ago

You can watch video of it on the NFL’s YouTube channel.

At the start of the overtime period, referee Jim Luckett asked Jerome Bettis of the Pittsburgh Steelers to call heads or tails.

Bettis clearly said, “Tails.”

Luckett heard “Heads” and declared that’s what Bettis said. A mistake!

November 26, 1998#Steelers #Lions
Phil Luckett 😖 @JeromeBettis36 #Thanksgiving pic.twitter.com/vDHsFy2TVh

— Old Time Football 🏈 (@Ol_TimeFootball) November 26, 2021

Bettis protested, but to no avail. The Lions’ captain, Robert Porcher, knew that Bettis had called tails, but wasn’t about to correct the official.

That coin toss mistake led to Detroit getting the ball first. After moving down the field a bit, they won the game on a Jason Hanson 42-yard field goal.

Under the more recent overtime rules, Pittsburgh would have gotten the ball back with a chance to tie or win the game.

At Least the NFL Learned and Adjusted

I’ll give credit to the NFL for learning from this mistake. They changed the rules and the procedure to one where the ref now had to ask the visiting team captain to call heads or tails before the coin flip. The back judge and field judge were also required to stay for the toss to have multiple witnesses.

I’m not sure that having multiple witnesses to a mistake really helps prevent anything.

But the old procedure, as seen in the video above, was more mistake prone. Luckett instructed Bettis to call the toss while the coin in the air.

A better procedure would involve some confirmation or what’s often called a “read back.”

1. Official asks player what they are calling
2. Player says heads or tails
3. Official repeats back for confirmation or correction, “The player called heads”
4. Pause and wait for possible correction by player or another official
5. Toss the coin

I’m sure the NFL is hoping that they won’t ever see a repeat of a similar mistake like this, especially in a high-stakes game like in the playoffs or, even worse, the Super Bowl.

Do your work processes run the risk of a verbal misunderstanding like this?

In healthcare, verbal orders are supposed to be read back for confirmation:

“JCAHO’s National Patient Safety Goal on verbal orders states that the receiver of the verbal or telephone order should write down the complete order to enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result.”

Without this, it’s too easy to hear the wrong medication or the wrong dose — a mistake more serious than botching the coin toss in a football game.

Possible mistakes in those settings include… these are mistakes that we must work really hard to prevent. And when they happen… we must learn from them.

For example:

1. A misheard verbal order led to a patient’s receiving erythromycin instead of azithromycin.
2. A nurse mistook a verbal order for Klonopin 0.1 mg when the intended medication was clonidine 0.1 mg.
3. A telephone order relayed to pharmacy by a nurse for “Viscerol” was clarified by pharmacy as Vistaril.      

Drug names are not the only information prone to misinterpretation. Numbers are also easily misheard. Examples of this type of error reported to PA-PSRS include:

1. A phone order mistaken for Toradol 50 mg was administered prior to the pharmacy review, when the intended dose was 15 mg.
2. A patient told a doctor that she regularly took five 30 mg phenobarbital tablets at bedtime, and the doctor wrote for 530 mg of phenobarbital. When the pharmacist called to clarify, the physician changed the order to 150 mg.
3. An emergency room nurse thought the physician stated that a patient was to receive “1 and 1/2 teaspoons” of Zithromax, which was given. In checking the written order, the dose was noted for 1/2 teaspoon.