ABSTRACT
Patient safety has concentrated on minimizing and subsequently eliminating potentially avoidable harm. Since 1990s, patient safety has developed into a specialty of its own with huge resources invested into it, its own terminology, and scientific journals dedicated to its study. The application of system thinking to patient safety relies on the acknowledgement that active errors will inevitably occur, through either omission or commission. Attempts to eliminate these errors by changing the behavior of individuals. Never events are a group of safety events that are preventable using established safety procedures and so are considered inexcusable and should never happen. The newborn surgical patient is susceptible to all of same hazards as any other surgical patient, but in addition, these patients have unique attributes that increase their vulnerability to harm during their care. Situational awareness relates to an individual's ability to gather and understand information that is available to him or her and to use this awareness to predict a future state.
