Brickell TA, Nicholls TL, Procyshyn RM, McLean C, Dempster RJ, Lavoie JAA, et al. Patient safety in mental health. Edmonton, Alberta: Canadian Patient Safety. Institute and Ontario Hospital Association.; 2009.
Thibaut B, Dewa LH, Ramtale SC, D’Lima D, Adam S, Ashrafian H, et al. Patient safety in inpatient mental health settings: a systematic review. BMJ Open. 2019;9(12):e030230.
Le Coze JC. Disasters and organisations: From lessons learnt to theorising. Saf Sci. 2008;46(1):132–49.
Hollnagel E. Barriers and accident prevention. USA: Ashgate; 2004.
Lundberg J, Rollenhagen C, Hollnagel E. What-you-look-for-is-what-you-find-The consequences of underlying accidents models in eight investigation manuals. Saf Sci. 2009;47:1297–311.
Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. London: CRC Press; 2014.
Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015;27(5):418–20.
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, et al. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017;26(5):381–7.
Svensson J. Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review. J Patient Saf. 2022;18(3):245–52. https://doi.org/10.1097/PTS.0000000000000885.
Bernert R, Hom M, Roberts L. A Review of Multidisciplinary Clinical Practice Guidelines in Suicide Prevention: Toward an Emerging Standard in Suicide Risk Assessment and Management, Training and Practice. Acad Psychiatry. 2014;38(5):585–92.
Layman DM, Kammer J, Leckman-Westin E, Hogan M, Goldstein Grumet J, Labouliere CD, et al. The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics. Psychiatr Serv. 2021;72(10):1118–25.
Stapelberg NJ, Sveticic J, Hughes I, Almeida-Crasto A, Gaee-Atefi T, Gill N, et al. Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses. Br J Psychiatry. 2021;219(2):427–36.
Carroll D, Kearney LK, Miller MA. Addressing suicide in the veteran population: Engaging a public health approach. Front Psych. 2020;11:1212.
Turner K, Stapelberg NJ, Sveticic J, Dekker SW. Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework. Aust N Z J Psychiatry. 2020;54(6):571–81.
Undrill G. The risks of risk assessment. Adv Psychiatr Treat. 2007;13:291–7.
Large M, Sharma S, Cannon E, Ryan C, Nielssen O. Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis. Aust N Z J Psychiatry. 2011;45(8):619–28.
RoosafHjelmsäter E, Ros A, Gäre BA, Westrin Å. Deficiencies in healthcare prior to suicide and actions to deal with them: a retrospective study of investigations after suicide in Swedish healthcare. BMJ Open. 2019;9(12):e032290.
Fröding E, Gäre BA, Westrin Å, Ros A. Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective. BMJ Open. 2021;11(3):e044068.
Large M, Smith G, Sharma S, Nielssen O, Singh SP. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand. 2011;124(1):18–29.
Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387–95.
Belsher BE, Smolenski DJ, Pruitt LD, Bush NE, Beech EH, Workman DE, et al. Prediction Models for Suicide Attempts and Deaths: A Systematic Review and Simulation. JAMA Psychiat. 2019;76(6):642–51.
Turecki G, Brent DA. Suicide and suicidal behaviour. The Lancet. 2016;387(10024):1227–39.
Mishara BL, Weisstub DN. Ethical and legal issues in suicide research. Int J Law Psychiatry. 2005;28(1):23–41.
Chu S. Special observations in the care of psychiatric inpatients: a review of the literature and developments in practice. ARC Journal of Psychiatry. 2016;1(1):21–31.
Large MM, Ryan CJ, Carter G, Kapur N. Can we usefully stratify patients according to suicide risk? BMJ. 2017;359:j4627.
Large M, Ryan C, Nielssen O. The validity and utility of risk assessment for inpatient suicide. Australasian Psychiatry. 2011;19(6):507–12.
Wears RL, Hollnagel E, Braithwaite J. Preface. In: Wears RL, Hollnagel E, Braithwaite J, editors. Resilient health care volume 2: The resilience of everyday clinical work. England: Ashgate; 2015.
Braithwaite J, Clay-Williams R, Nugus P, Plumb J. Health Care as a Complex Adaptive System. In: Hollnagel E, Braithwaite J, Wears RL, editors. Resilient Health Care 1. England: Ashgate Studies in Resilience Engineering; 2013.
Ellis LA, Churruca K, Clay-Williams R, Pomare C, Austin EE, Long JC, et al. Patterns of resilience: A scoping review and bibliometric analysis of resilient health care. Saf Sci. 2019;118:241–57.
Wiig S, Aase K, Billett S, Canfield C, Røise O, Njå O, et al. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res. 2020;20(1):330.
Ellis LA, Churruca K, Braithwaite J. Mental health services conceptualised as complex adaptive systems: what can be learned? Int J Ment Heal Syst. 2017;11(1):43.
Berg SH, Akerjordet K, Ekstedt M, Aase K. Methodological strategies in resilient health care studies: An integrative review. Saf Sci. 2018;110:300–12.
O’Hara JK, Aase K, Waring J. Scaffolding our systems? Patients and families ‘reaching in’as a source of healthcare resilience. BMJ Qual Saf. 2019;28(1):3–6.
Quinlivan L, Littlewood DL, Webb RT, Kapur N. Patient safety and suicide prevention in mental health services: time for a new paradigm? J Ment Health. 2020;29(1):1–5.
Laugaland K, Aase K. The demands imposed by a health care reform on clinical work in transitional care of the elderly: a multi-faceted janus. In: Wears RL, Hollnagel E, Braithwaite J, editors. Resilient health care volume 2; The resilience of everyday clinical work. England: Ashgate; 2015.
O’Hara JK, Baxter R, Hardicre N. ‘Handing over to the patient’: A FRAM analysis of transitional care combining multiple stakeholder perspectives. Appl Ergon. 2020;85:103060.
Jun GT, Canham A, Noushad F, Gangadharan SK, editors. Safety I and Safety II for Suicide Prevention – Lessons from How Things Go Wrong and How Things Go Right in Community-Based Mental Health Services. Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018); 2019; Cham: Springer International Publishing.
Littlewood DL, Quinlivan L, Graney J, Appleby L, Turnbull P, Webb RT, et al. Learning from clinicians’ views of good quality practice in mental healthcare services in the context of suicide prevention: a qualitative study. BMC Psychiatry. 2019;19(1):346.
Berg SH. From Safety-I to Safety-II: Toward new perspectives on patient safety in suicide prevention. Suicidologi. 2021;26(2):34–45.
Yin RK. Case study research: design and methods. Los Angeles, CA: Sage Publications; 2014.
Berg SH, Rørtveit K, Aase K. Suicidal patients’ experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies. BMC Health Serv Res. 2017;17(1):73.
Berg SH, Rørtveit K, Walby FA, Aase K. Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences. BMJ Open. 2020;10(11):e040088.
Berg SH, Rørtveit K, Walby AF, Aase K. Adaptive capacities for safe clinical practice for patients hospitalised during a suicidal crisis: A qualitative study. BMC Psychiatry. 2020;20:316.
Berg SH, Rørtveit K, Walby FA, Aase K. Safe clinical practice for patients hospitalised in a suicidal crisis: a study protocol for a qualitative case study. BMJ Open. 2017;7(1):6.
Berg SH. Safe clinical practice for patients hospitalised in mental healthcare during a suicidal crisis. PhD thesis. https://hdl.handle.net/11250/2675498. University of Stavanger2020.
Berg SH, Rørtveit K, Walby FA, Aase K. Interview guide [supplemental material]. BMJ Open. 2020;6(11):e040088.
Berg SH, Rørtveit K, Walby FA, Aase K. Interview guides [Supplemental material]. BMC Psychiatry. 2020;20. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-02689-8#Sec27. Accessed 1 Feb 2022.
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med. 2009;6(7):e1000100.
Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:1–10.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.
Morse JM. Mixed method design: Principles and procedures. London and New York: Routledge; 2009.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.
Dahlberg K, Dahlberg H, Nystrøm M. Reflective Lifeworld Research. Sweden 2008.
Norwegian Directorate of Health. National guidelines for prevention of suicide in mental health care systems. IS-1511. Oslo 2008 [Available from: https://www.helsebiblioteket.no/psykisk-helse/aktuelt/her-finner-du-retningslinjer-for-selvmordsforebygging.
Brudvik M, Ness E, Walby FA. Suicide prevention in acute psychiatric units: experiences from a national learning network. Suicidologi. 2014;19(2):7–12.
Norwegian Institute of Public health. Suicide as cause of death 2021 Available from: https://www.fhi.no/hn/helseregistre-og-registre/dodsarsaksregisteret/selvmord-i-dodsarsaksstatistikken/.
World Health Organization. Preventing Suicide: A global imperative Geneva2014 Available from: https://apps.who.int/iris/handle/10665/131056.
Quin P. Suicides in Norway in 2017 National Centre for suicide research and prevention 2018 [Available from: https://www.med.uio.no/klinmed/forskning/sentre/nssf/kunnskapsressurser/statistikk-selvmord/2017_statistikk-nettpresentasjoner-norsk_endelig.pdf.
Regjeringen.no. The Governments Action plan for prevention of suicides 2020–2025 Regjeringen.no: The Norwegian Government; 2020 [Available from: https://www.regjeringen.no/contentassets/ef9cc6bd2e0842bf9ac722459503f44c/regjeringens-handlingsplan-for-forebygging-av-selvmord-2020-2025.pdf.
Walby FA, Myhre MØ, Kildahl AT. 1910 dead patients: Suicide within one year after contact with mental health- and substance misuse services 2008–2015 – a national registry study from Norway National Centre for Suicide Research and Prevention, Norway: University of Oslo; 2018 [Available from: https://www.med.uio.no/klinmed/forskning/sentre/nssf/kartleggingssystemet/dokumenter/rapporter/nssf_kartleggingssystemet_rapport_web_korrigert_p.pdf.
Tracy SJ. Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qual Inq. 2010;16(10):837–51.
Bergström J, van Winsen R, Henriqson E. On the rationale of resilience in the domain of safety: A literature review. Reliability Engineering & System Safety. 2015;141:131–41.
Iflaifel M, Lim RH, Ryan K, Crowley C. Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience. BMC Health Serv Res. 2020;20:1–21.
Berg SH, Aase K. Resilient Characteristics as Described in Empirical Studies on Health Care. Exploring Resilience A Scientific Journey from Practice to Theory. SpringerBriefs in Applied Sciences and Technology. SAFETY MANAGEMENT: Springer Nature; 2019. p. 79–87.
Hagen J, Knizek BL, Hjelmeland H. Mental Health Nurses’ Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor. Arch Psychiatr Nurs. 2017;31(1):31–7.
Cutcliffe JR, Stevenson C. Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (Part two). Ment Health Nurs. 2008;17(5):351–62.
Cutcliffe JR, Stevenson C. Feeling our way in the dark: The psychiatric nursing care of suicidal people—A literature review. Int J Nurs Stud. 2008;45(6):942–53.
Waern M, Kaiser N, Renberg ES. Psychiatrists’ experiences of suicide assessment. BMC Psychiatry. 2016;16(1):440.
Aflague JM, Ferszt GG. Suicide Assessment by Psychiatric Nurses: A Phenomenographic Study. Issues Ment Health Nurs. 2010;31(4):248–56.
Klein G. Naturalistic decision making. Human Factors. 2008;50:456–60.
Klein G, Moon B, Hoffman RR. Making sense of sensemaking 1: Alternative perspectives. IEEE Intell Syst. 2006;21(4):70–3.
Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187–232.
Runeson B, Odeberg J, Pettersson A, Edbom T, Jildevik Adamsson I, Waern M. Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence. PLoS ONE. 2017;12(7):e0180292.
Tenney YJ, Pew RW. Situation awareness catches on: what? so what? now what? Rev Hum Factors Ergon. 2006;2(1):1–34.
Siegel AW, Schraagen JM. Team reflection makes resilience-related knowledge explicit through collaborative sensemaking: observation study at a rail post. Cogn Technol Work. 2017;19(1):127–42.
Malakis S, Kontogiannis T. Exploring team sensemaking in air traffic control (ATC): insights from a field study in low visibility operations. Cogn Technol Work. 2014;16(2):211–27.
Anderson JE, Ross AJ, Macrae C, Wiig S. Defining adaptive capacity in healthcare: A new framework for researching resilient performance. Appl Ergon. 2020;87:103111.
Wears RL, Schubert CC, Hunte G, S. Individual-collective Trade-offs: implications for resilience In: Wear RE, Hollnagel E, Braithwaite J, editors. Resilient health care volume 2. England/Usa: Ashgate 2015.
Plumb J. Taming uncertainty? Performance, personalisation and practices of patient safety in an Australian mental health service. In: Institutional respository of UNSW Australia. Australian Institute of Health Innovation, Faculty of Medicine, UNSW2013 [Available from: http://www.unsworks.unsw.edu.au/primo_library/libweb/action/dlDisplay.do?vid=UNSWORKS&docId=unsworks_11424&fromSitemap=1&afterPDS=true.
Santos A, Wauben L, Guilavogui S, Brezet J, Goossens R, Rosseel P. Safety challenges of medical equipment in nurse anaesthetist training in Haiti. Appl Ergon. 2016;53:110–21.
Foster CJ, Plant KL, Stanton NA. Adaptation as a source of safety in complex socio-technical systems: A literature review and model development. Saf Sci. 2019;118:617–31.
Hollnagel E, Paries J, Woods DD, Wreathall J. Resilience engineering in practice: A guidebook. Hollnagel E, Paries J, Woods DD, Wreathall J, editors. England: Ashgate Studies in Resilience Engineering; 2011.
King A, Daniels J, Lim J, Cochrane DD, Taylor A, Ansermino JM. Time to listen: a review of methods to solicit patient reports of adverse events. Qual Saf Health Care. 2010;19(2):148–57.
Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1):e001570.
Mollon D. Feeling safe during an inpatient hospitalization: a concept analysis. J Adv Nurs. 2014;70(8):1727–37.
Rørtveit K, Sætre Hansen B, Leiknes I, Joa I, Testad I, Severinsson E. Patients’ Experiences of Trust in the Patient-Nurse Relationship—A Systematic Review of Qualitative Studies. Open J Nurs. 2015;5:195–209.
Jobes DA. The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence-Based Clinical Approach to Suicidal Risk. Suicide and Life-Threatening Behavior. 2012;42(6):640–53.
Jobes DA, Comtois KA, Gutierrez PM, Brenner LA, Huh D, Chalker SA, et al. A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers. Psychiatry. 2017;80(4):339–56.
Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–66.
Linehan M. Skills training manual for treating borderline personality disorder. New York: Guilford press; 1993.
Endsley M, Endsley MR. Toward a Theory of Situation Awareness in Dynamic Systems. Hum Factors J. 2017;37(1):32–64.
Mathieu JE, Heffner TS, Goodwin GF, Salas E, Cannon-Bowers JA. The influence of shared mental models on team process and performance. J Appl Psychol. 2000;85(2):273–83.
Gillespie BM, Gwinner K, Fairweather N, Chaboyer W. Building shared situational awareness in surgery through distributed dialog. J Multidiscip Healthc. 2013;6:109–18.
Ancona D. Framing and Acting in the Unknown. S Snook, N Nohria, & R Khurana, The Handbook for Teaching Leadership. 2012:3–19.
Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):978–88.
Flynn S, Nyathi T, Tham SG, Williams A, Windfuhr K, Kapur N, et al. Suicide by mental health in-patients under observation. Psychol Med. 2017;47(13):2238–45.
Cutcliffe JR, Barker P. Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations.’ J Psychiatr Ment Health Nurs. 2002;9(5):611–21.
Cardell R, Pitula CR. Suicidal inpatients’ perceptions of therapeutic and nontherapeutic aspects of constant observation. Psychiatr Serv. 1999;50(8):1066–70.
Vraale GB, Steen E. The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation. J Psychiatr Ment Health Nurs. 2005;12(5):513–8.
Cutcliffe JR, Stevenson C, Jackson S, Smith P. Reconnecting the person with humanity: how psychiatric nurses work with suicidal people. Crisis. 2007;28(4):207–10.
Cutcliffe JR, Stevenson C, Jackson S, Smith P. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Stud. 2006;43(7):791–802.
Holden LM. Complex adaptive systems: concept analysis. J Adv Nurs. 2005;52(6):651–7.
Patterson MD, Wears RL. Resilience and precarious success. Reliab Eng Syst Saf. 2015;141:45–53.
Ekstedt M, Ödegård S. Exploring gaps in cancer care using a systems safety perspective. Cogn Technol Work. 2015;17(1):5–13.
Ross AJ, Anderson JE, Kodate N, Thompson K, Cox A, Malik R. Inpatient diabetes care: complexity, resilience and quality of care. Cogn Technol Work. 2014;16(1):91–102.
Carlen P, Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs. 2007;16(4):257–65.
Gilje F, Talseth AG, Norberg A. Psychiatric nurses’ response to suicidal psychiatric inpatients: struggling with self and sufferer. J Psychiatr Ment Health Nurs. 2005;12(5):519–26.
Tzeng WC, Yang CI, Tzeng NS, Ma HS, Chen L. The inner door: toward an understanding of suicidal patients. J Clin Nurs. 2010;19(9/10):1396–404.
Takahashi C, Chida F, Nakamura H, Akasaka H, Yagi J, Koeda A, et al. The impact of inpatient suicide on psychiatric nurses and their need for support. BMC Psychiatry. 2011;11(1):38.
Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;34(5):1189–208.
Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753–60.
Graneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today. 2017;56:29–34.
Patton MQ. Qualitative research and evaluation methods. Thousand Oakes: Sage; 2002.
Malterud K. Qualitative research: standards, challenges, and guidelines. The Lancet. 2001;358(9280):483–8.
Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry. 2016;3(7):646–59.
Bowers L, Alexander J, Bilgin H, Botha M, Dack C, James K, et al. Safewards: the empirical basis of the model and a critical appraisal. J Psychiatr Ment Health Nurs. 2014;21(4):354–64.
NICE. Self-Harm: The NICE Guideline on Longer-Term Management: National Clinical Guideline Number 133–National Collaborating Centre for Mental Health National Institute of Health and Excellence The British Psychological Society and The Royal College of Psychiatrists London; 2011 [Available from: https://www.nice.org.uk/guidance/cg133.
While D, Bickley H, Roscoe A, Windfuhr K, Rahman S, Shaw J, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. The Lancet. 2012;379(9820):1005–12.
Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS ONE. 2014;9(2):e89944.
Polit DF, Beck CT. Generalization in quantitative and qualitative research: Myths and strategies. Int J Nurs Stud. 2010;47(11):1451–8.