In this issue, Amalberti and Vincent1 ask ‘what strategies we might adopt to protect patients when healthcare systems and organizations are under stress and simply cannot provide the standard of care they aspire to’. This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. The authors provide guidance for addressing this tension of providing safe care during times of organisational stress, including principles for managing risk in difficult conditions, examples for managing this tension in other high-risk industries, and a research and development agenda for healthcare. Leaders at all levels of healthcare organisations should read this article. These authors join others2 who advise that we should shift our focus from creating absolute safety (meaning the elimination of error and harm) towards doing a better job of actively managing risk. I want to expand on this point to explore how an excessive focus on absolute safety may paradoxically reduce safety. Striving for absolute safety—often termed ‘zero harm’—is encouraged by some consultants, patient safety experts and regulators. Take for example the recently published book, ‘ Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare ’ ,3 edited by three leaders of Press Ganey, a large organisation that works with over 26 000 healthcare organisations with the mission of helping organisations improve patient experience, including improving safety. The book states, ‘We will only reduce serious safety events, and improve organizations’ overall performance, if every US …