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Using perioperative patient safety guidelines to drive systems change. A European consensus study in this issue addresses perioperative patient safety recommendations by synthesising multiple patient safety guidelines covering the entire patient journey to provide a single point of reference. In this editorial we address what is considered as evidence and seek inclusion of broader ways of knowing and understanding the complexity of safety in healthcare. We suggest prioritising feasibility could limit improvements to specific clinical practices rather than systems-wide change. Safety is more than a collection of isolated recommendations. Safety interventions should be seen as part of a complex technical sociocultural system. Improvements in care require a change in culture and institutional priorities and a systemic approach to patient safety.