This editorial builds on the discussion from a study suggesting that overall improvement in the adoption and implementation of patient safety systems is slow. The authors offer a series of explanations for these delays in important improvements and apply the concept called the "theory of constraints." This theory asks the question of what should change, to what should it change, and how should change occur. Responses are framed with discussion of six thought processes that must occur at an organization for change to become possible. These include agreement that a problem exists, agreement that a proposed solution actually solves the problem, and identifying obstacles and how they can be overcome. The authors argue that sustained change occurs only when these root causes receive appropriate exploration and direct action in fostering improved safety systems.