The Chief Medical Officer's recent report, 'Making surgery safer', was a response to widespread concern about patient safety in the operating theatre. Annually there are an estimated 129,416 'untoward events' in the UK. These range from 'near misses' (NM), in which a patient is 'nearly harmed', to an 'adverse event' (AE), usually defined as 'an unintended injury or complication, including death'.

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