The Safety Committee recommends that systems need to be in place so that the entire multidisciplinary theatre team are aware of the positioning and visibility of every clamp and every line. This awareness needs to explicit and documented. A protocol-based system should be developed to ensure that there is verbal acknowledgement by each member of the team when each clamp is applied and removed, and when each line is inserted and removed. This verbal communication should be supplemented by preoperative team briefings that include a discussion of the operative strategy regarding conduct of bypass and a visual record of this strategy should be displayed in theatre (possibly on a whiteboard). These protocols and discussions need to address all aspects of the conduct of bypass, relevant to this specific case they must include the strategy of weaning and de-cannulation.