The complexity of treatment, procedures, interventions, and workload of modern, inpatient paediatric and neonatal care provides a setting where errors may, potentially, have serious adverse consequences for our patients. For the purpose of this article, an error is defined as clinical performance which deviates from an ideal and, as a result, could (or does) lead to an accident or an iatrogenic incident.1 ,2 Active errors are those that immediately precede an adverse event and latent errors are factors inherent to a system (for example, heavy workload, inadequate maintenance of equipment, or the prevailing professional culture) that provide the conditions in which an accident is inevitable if given the right set of circumstances. Since all physicians involved with acute or emergency care may be expected to perform practical procedures,3 we need to understand why our patients sometimes suffer as a consequence of a procedure, what mistakes occur, and how we can improve on our performance.