Safe and high quality health care is an objective that everybody supports. With so much written about it and everybody committed to it, why are we still struggling to achieve it? The successful acceptance and adoption of casemix provides some clues as to the answer. This paper examines the factors that assisted casemix and the obstacles to achieving progress with safety and quality. It concludes that both the health industry and community's tolerance of risk in health is too high. The lessons from the casemix story can be applied to advance the safety and quality agenda. A good place to start is a determined campaign focussing on improving safety.