Mistakes, errors, misunderstandings and misinterpretations, occur in every workplace. It is just how it is, when dealing with people, complex issues or situations, work pressure, ongoing demands and the like. What also happens in many workplaces when unfortunate and unexpected things happen from time to time, is that the situation is looked at and the issue is resolved as quickly as possible, through problem solving, and life goes on. Yet what often gets forgotten is the value in conducting an in-depth review on how procedures, systems or people may have contributed to the event; what may need to change, to prevent something happening again; and a formal process of making any necessary changes to systems, procedures or people's job descriptions, to prevent it happening again. A documented, formal, critical incident review process enables a situation to be looked at in its entirety, not just the presenting problem and learnings to be taken, from the event.