What's in My Buckets Today? Foreseeing and Forestalling Patient Harm

Operating theatre teams work in an imperfect system characterised by time pressure, goal conflicts, lack of team stability and steep authority gradients between consultants and other team members. Despite this, they often foresee and forestall errors that could harm patients. The paper discusses the strengths and limitations of using Reason's three buckets model of error prevention as a framework for training operating theatre staff how to foresee and forestall incidents.