Penfold and colleagues, in this issue of Healthcare Papers, provide a comprehensive and substantive critique of the hospital standardized mortality ratio (HSMR) as a measure of patient safety, and suggest a useful alternative. However, although measurement is not trivial, new thinking about patient safety presents a much greater challenge than just issues related to measurement. The measurement issue highlights the need for a re-conceptualization of what it takes, from a systems perspective, to achieve safety. This commentary first reviews Penfold et al.'s arguments (agreeing with their conclusions regarding the HSMR). It then presents some key elements of the new thinking about patient safety, particularly the emerging concepts of resilience and resonance, and notes how and why these are beginning to be applied in healthcare. Finally, it considers a number of reasons why a more comprehensive adoption of these new perspectives may be prolonged and notes that, while difficult, the journey is worth taking.

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