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Too often, seemingly simple interventions are implemented without fully considering how the intervention might achieve the desired results, whether it can cause harm, or whether a different intervention should be considered.1–3 The tendency to favour rapid cycle implementation over analysis and measurement represents a common pitfall in quality and safety studies.4 Quality improvement and patient safety (QIPS) studies often omit the critical details underlying the success (or lack thereof) of the intervention, in part due to the perception that simple interventions do not require rigorous measurement.3 4 Consequently, reported measures often solely focus on the outcomes rather than the mechanisms and processes that led to the outcomes.