The purpose of this article is to share a recovery room practitioner's experience using reflection and to explore the issues surrounding extubation in the post anaesthetic care unit (PACU). Currently there are no national standards of practice for practitioners' learning and safe practice of extubation techniques within the PACU. Therefore, the possibility of an adverse incident is significantly increased, potentially causing harm to the patient and damage to any hospital's reputation as well as the practitioners' profession. The authors wish to identify the concerns by citing a clinical incident that lead to reflection and sharing of the experience through this article.