It staggers the imagination when you think of the number and types of potential mistakes that lie in wait for patients in any healthcare setting, especially one as procedure-intensive as a surgical center (see "Potential Near-miss Situations"). Yet with most facilities' high safety records, it's all too easy to be lulled into a false sense of security. All it takes is one error with devastating patient harm to shatter the spirit and confidence of the entire staff. But what about when we nearly make a mistake? As part of a comprehensive safety program, it's important to identify, report, analyze and discuss near-misses.