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It is amazing that it is 30 years since the core text supporting the Manchester Triage System, now generally known as the MTS, was first published. It feels like yesterday that the senior clinicians leading the local delivery of emergency medicine in what were accident and emergency departments in Greater Manchester were having weekly meetings during which they crafted the MTS as our local solution to our local problem. Since then, the MTS has been adopted by many urgent and emergency care systems around the world. It has also been joined by the very successful Manchester Telephone Triage and Advice (TTA) system that was derived as a support to the first book and is based on the same principles. Fundamentally the system has not drastically changed since the first edition, which is testament to the vision, rigour and thousands of person hours poured into that first iteration. The fourth edition of Emergency Triage offers a complete rewrite of all the chapters, with detailed advice on how to successfully implement and sustain the MTS. At times it may read more like a manual than a reference book with the inclusion of case studies to enhance understanding, clearly setting out the ‘how to use MTS in practice’. The charts are not dramatically different, there is one new chart, and the major incident charts are abandoned. The biggest change comes with the reordering of discriminators into a strict hierarchy, that flows through all charts and level of priority, to strengthen decision making by selection of the highest order discriminator each time the system is used. By far the biggest change to the MTS, since the original publication, comes from a new approach to the triage of patients in acute mental health crisis. This change is based on a focused Delphi study that included experts from six stakeholder groups and was designed to encourage parity of esteem between patients with mental health and physical health presentations. The results have been operationalised by incorporating 19 new discriminators into the existing presentation flow charts. Perhaps the most significant changes are invisible to the clinical triage practitioner. These involve the governance structures that have been put in place to standardise the international decision-making processes, and a re-energised effort to continuously assess and improve quality. Our role as editors of this book and as members of the Manchester Triage Executive Board, that ultimately makes the decisions regarding content, is to make sure the tool is usable, accurately represents best clinical practice and supports the delivery of good inter-and intra-user reproducibility. Your role as triage practitioners using this tool is to use it correctly. Outcomes of triage that result from using the tool incorrectly are not MTS errors, but rather errors of triage delivery. Training and continuous quality measurement and improvement are key to this standard being upheld.