The call for better reporting, a more open culture, better mechanisms for ensuring that necessary changes are made, and a much wider appreciation of the value of the systems approach is welcome. The cornerstone of the recommendations is a greatly enhanced system of national reporting of adverse events. Although the benefits of such a programme seem self-evident, two questions must be addressed before proceeding with such a plan—namely: “Why aren't these events being reported now?” and “What would be the cost of such a system?”