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This article reviews of some of the key topics and challenges in quality, safety, and the measurement and improvement of outcomes in anaesthesia. The topics were selected based on the perspective of an individual with quality and safety expertise and recent experience of the specialty in both the UK and USA. The review does not seek to be exhaustive or systematic, but to highlight current areas of concern and potential solutions. The topic is subdivided into sections where the system of health care is viewed from different levels. These levels are as follows: the microsystem or patient and individual clinician perspective; the meso or hospital perspective; and the macro or government and policy perspective. Topics covered include medication safety, changes in approaches to patient safety, payment reform, longer term measurement of outcomes, large-scale improvement programmes, the ageing population, and burnout. The article begins with a section on the success of the specialty of anaesthesia in improving the quality, safety, and outcomes for our patients, and ends with a look to future developments, including greater use of technology and patient engagement.