INTRODUCTION This article aims to highlight an incident in theater where environmental pressure has a tendency to lead to human error, thus compromising patient safety. Reflect and critically analyze the situation, human factors, theories, guidelines and national policies governing the theater environment so as to improve practice, increase awareness and prevent adverse events, thereby improving patient safety in theaters . Nurses are constantly encouraged to be thoughtful professionals (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 professional to think and examine his actions and behaviors, thus aids in his 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 behaviors to ensure 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) states that there are two basic forms of reflection: reflection on action and reflection in action. He also defined reflection-in-action as a means of examining one's own behavior and that of others while 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 the aim of improving professional composition. .ry.Furthermore, the circulating person would have to keep the bowl container inside the operating room until the operation was completed, and until the final counting was completed and everything that had been accounted for at the beginning was taken out of the case. 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 operating theatre. In line with standard infection control precautions, fluid drawn into the sluice should be aspirated via the suction tube into the suction liner. NICE guidance (2012) states that healthcare associated infections are caused by a wide range of microorganisms. These are often carried by patients themselves and have taken advantage of a route within the body provided by an invasive device or procedure.