The failure here isn't mostly that a card was designed wrong - that could happen for anyone briefly given the task of designing and printing up cards.
The travesty is that a company that is presumably being paid MILLIONS of $ to do this job, was skating by with non-thinking process and doing deliberate testing and rethinking of the card design. They got lazy and assumed that every year, nothing goes wrong, so we don't need to be checking or improving what we do. (with regard to the actual big night's event, not saying there's not other work that goes into it)
If something is that important, imagine what you should do to make it as bulletproof as possible - like you're designing cards that hold the nuclear launch codes upon which millions of lives depend. You would create a design and testing process that:
- tested what would happen if some element of the card delivery / reading chain failed or was accidentally broken
- tested different card typography and layout designs
- tested the kinds of people who would be involved in delivering and reading the cards (e.g. blind people, old people, nearsighted people, drunk people, anyone who you'd likely encounter on the night)
- etc, etc, etc.
They got by for years without being rigorous about this part of their job, and this time it bit them in the ass. Don't get complacent.