Two aims of increasing importance in clinical and quality management are identifying areas of iatrogenic risk and improving patient safety. In this issue of CHEST (see page 1315), Duncan et al2 describe a complex and comprehensive intervention performed by personnel in an academic pulmonary medicine group practice that is designed to reduce the risk of pneumothorax after outpatient thoracenteses. The authors emphasize the component of the intervention that uses experiential training in a zero-risk (simulation) environment. Simulation-based experiential learning was an important part of their intervention. We would submit, however, that this study is much more complicated than just a “training story.” We believe that one of the important lessons of the article by Duncan and colleagues2 is that training alone is rarely enough; it is system analysis and process change, reinforced by intensive training and changes in medical culture, that really are the linchpins of the safest clinical practices and process improvements in health care.