It is generally accepted that the theatre is a highly technical and complex environment where clinical risks need to be managed effectively to ensure safe practice and to limit liability and litigation. Although anaesthesia and post anaesthesia care has long been the focus of risk management, the potential for errors and adverse events remains high. When errors occur, it is important to analyse the causes, so that preventative measures can be taken and similar incidents do not reoccur. This article sets out to examine and evaluate the process of reflection using a critical incident approach. A model of reflective practice, as suggested by Johns [1996] has been used to structure this paper. A critical incident is described and key issues arising from it are discussed and reflected upon. This incident was chosen because important clinical and risk management issues were highlighted.