[A cultural shift is needed to improve patient safety]

In a recently published thesis, we propose a cultural shift in the assessment of suicide as an incident of severe patient harm, from a focus on errors and an often speculative avoidability, to healthcare's ability of risk management over time. Patient safety work needs to change in line with the development of knowledge in patient safety. This means a cultural change in the view of patient safety, with a clearer focus on healthcare's abilities in risk management and learning. Legislation and regulations regarding healthcare and the supervisory authority need to support this cultural change in assessment and investigations of patient harm.  A shift from a focus on errors and deviations to quality and positive outcomes of care, proactive patient safety work, risk management, patient safety culture and management commitment is needed.