INTRODUCTIONThis article aims to highlight an incident in theater where environmental pressure tends to lead to human error, thereby compromising patient safety. Critically reflect and analyze the situation, human factors, theories, guidelines and national policies that govern a theater environment in order to improve practice, raise awareness and prevent adverse events, thereby improving patient safety in theaters. Nurses are constantly encouraged to reflect. practitioners (Sommerville and Keeling, 2004). Reflective practice can be defined as the process of making sense of events, situations and actions that occur in the workplace (Oelofsen, 2012; Boros, 2009). It helps the practitioner to reflect and examine their actions and behavior, thus facilitating their learning and improvement. Reflective practice is important for nurses. The NMC Code (2002) states that nurses are responsible for providing care to the best of their ability to patients and their families. As nurses, according to Sommerville and Keeling (2004), they must focus on their knowledge, skills and behavior to ensure that they are able to meet the demands placed on them by this commitment. Identifying strengths allows nurses to learn, develop, and grow professionally. A suggestion made by Schon (1991) indicates that there are two basic forms of reflection: reflection on action and reflection on action. He further defined reflection in action as a means of examining one's own and others' behavior in a situation (Schon, 1995, 1987). However, Grant and Greene (2001) and Revans (1998) defined reflection on action as focusing on identifying negative aspects of personal behavior with a view to improving professional skills.... middle of the article ..... .ry.Furthermore, the person circulating should have kept the bowl liner inside the theater until the operation was completed, and the final count had been undertaken and that everything that was accounted for at the beginning of the case has been removed. Local Trust Policy (c) (2012) states that at no time should linen, clinical waste in orange bags and non-clinical waste containers, including suction liners, leave the theatre. In accordance with standard infection control precautions, liquid collected from the sluice should have been drawn through a suction tube to the suction liner. NICE guidelines (2012) state that hospital-acquired infections are caused by a wide range of micro-organisms. These are often carried by the patients themselves and have taken advantage of a route to the body provided by an invasive device or procedure..