Patient safety took the spotlight when the public became increasingly aware that hospitals were not safe places for patients [2]. High profile reports in the US and UK highlighted the negative impact of medical errors [3, 4]. They emphasised the high prevalence of medical errors and the importance of learning from them. Preventable deaths caused by medical errors in US hospitals were reported to range between 44,000–98,000 per year [5]. In the UK, a review of 1014 patient records showed that over 10 % of patients suffered an adverse event in hospital, half of which were considered preventable [6]. Since then, the figure of 1 out of 10 patients being harmed has been supported and a case made that a significant number of these are unacceptable and preventable [7].

The operating theatre is one of the most hazardous settings for the patient, holding a record for the highest number of adverse events [8]. Over half of such adverse events are considered to be preventable and these figures are also specialty-dependent, with vascular surgery and colonic surgery holding the highest number of preventable adverse events [9].

Surgeons undoubtedly understand the doctrine of ‘first, do no harm’, which begs the question – why are avoidable incidents so high? As Reason [10] explains, errors are not caused by individuals alone. His ‘Swiss cheese model of organisational accidents’, suggests that it is an alignment of ‘active errors’ (individual mistakes, slips, lapses and violations) and ‘latent failures’ (dormant system problems) that lead to harmful outcomes [10]. Accordingly, strategies to reduce surgical errors today are aimed at improving healthcare systems and their processes.

The World Health Organization (WHO) surgical safety checklist has been the largest strategy to reduce errors in surgery [11]. It was introduced with the aim of reducing the rates of death and major complications post surgery. The checklist comprises of a set of procedures with tick boxes at three time points: before (‘sign in’), during (‘time out’) and after (‘sign out’) an operation. Procedures include checking known allergies of the patient, confirming all team members have introduced themselves and checking whether there are any equipment concerns.