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Quality improvement (QI) is increasingly used as a mechanism to improve care and outcomes in healthcare. It is defined as the application of a systematic approach to solve a complex issue, involving those closest to the issue in discovering new solutions, testing these in practice and learning from the use of data.1 However, despite everyone’s best intentions, QI efforts often fail. Just like the way the holes in James Reason’s Swiss Cheese align when patient safety events occur, the reasons QI projects fail are multifactorial.2