Part of my job as an Anaesthesia Quality and Safety Fellow is to monitor reports made though our Anaesthesia Safety Monitoring Project, which allows staff to report latent safety threats, near-misses, faulty or badly designed equipment and pretty much anything that might pose a threat to patient safety. Below is the text of a “Letter to the Editor” that I wrote explaining how we were able to quickly and cheaply respond to an issue highlighted by one of these reports. The letter was published in the Canadian Journal of Anesthesia, and it can be accessed here (login required) or viewed online here by anyone.