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In their article regarding high-reliability organisations, Sutcliffe et al1 argue that healthcare's failure to understand the fundamental concepts that underlie high reliability has limited their impact on patient safety and healthcare quality. In considering their claims, an important issue arises that extends beyond the pursuit of high reliability: the failure within healthcare to develop a nuanced understanding of the theoretical basis for improvement methodologies. More specifically, the pressure to pursue quality improvement (QI) initiatives may presently exceed our expertise for achieving them successfully. This is an issue that, if not addressed, may compromise future attempts to improve …