This article is a reflective account of a near miss that happened in clinical practice during a particularly busy operating list. This critical incident highlights issues that can arise from a breakdown of communication between members of a multidisciplinary team and demonstrates how ineffective teamwork can jeopardise a patient's safety and wellbeing. It emphasises the effects of human factors on professional performance and how they can contribute to mistakes and misconducts. It also stresses the importance of reporting patient safety incidents so that the lessons can be learned and future practice improved.
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