The use of high intensity focused ultrasound (HIFU) in surgical applications has continued to grow at a rapid pace. Nevertheless, safety concerns limit the adoption of ultrasound guidance due to the persistent lack of real‐time monitoring and quantitative measures of clinical endpoints. Imaging and temperature estimation using magnetic resonance remains the preferred approach for guidance and monitoring in much of the Western world, while ultrasound imaging has seen wide use in China. Recent reviews of clinical outcomes have raised new regulatory concerns in China and are likely to increase scrutiny elsewhere. Still lacking are near real‐time measures of in situ parameters such as acoustic power, heating rate, or temperature, from which clinical endpoint metrics may be obtained with acceptable accuracy. Furthermore, therapy planning remains a semiquantitative process, producing highly variable results, particularly in the absence of feedback. This presentation provides an update on the clinical impact of insufficient quantification of ultrasound‐guided HIFU therapy.