In this issue of Quality and Safety in Health Care, there is a paper that should stimulate considerable debate (see page 99);1 indeed, we have published three commentaries alongside the paper2^–4 to initiate this and a further response from the authors (see page 90).5 Despite major initiatives to improve patient safety, there is a perception that attempts to improve safety have made slow progress. Hence, Coiera and Braithwaite argue for the implementation of market based control mechanisms as an incentive to promote patient safety. Their proposal is modelled on the “cap and trade” approach to creating a market in emissions trading, a key component of the Kyoto protocol that allows organisations that are successful in reducing carbon emissions to sell credits to organisations that have been less successful.

The parallel between emissions trading to improve the environment and patient safety event trading to improve healthcare safety is fascinating; each of our commentators is intrigued by the proposal. However, each of them believes that the model, while intriguing, is unlikely to be implemented or effective. Coiera and Braithwaite have responded to these commentaries with a further …