I suppose the process of acceptance will pass through the usual four stages:

1. This is worthless nonsense,

2. This is an interesting, but perverse, point of view,

3. This is true, but quite unimportant,

4. I always said so.

JBS Haldane Journal of Genetics 1963; 58(3), 464.

Few would disagree that it is good idea to provide clinicians with incentives to improve performance. Others propose sanctions for clinicians who do not meet clinical standards. Our proposal sees both propositions as the matching halves of a feedback control system, with “patient harm” the variable to be controlled. In these three thoughtful commentaries, we see the beginning of a necessary dialogue to reshape safety research and policy. The debate comes from different traditions, including health services, economics, governance and systems control. Finding a common language and theoretical foundation will take time.

It is fascinating to see, in the Donaldson and Meltzer commentaries, two mutually exclusive stories about why a safety market will not work.12 …