This article explores an apparent paradox of stability and change in patient safety thinking and practice. The dominant approach to patient safety has largely been focused on closing ‘safety gaps’ through standardisation in seemingly stable healthcare systems. However, the presupposition of system stability and predictability is presently being challenged by critics who insist that healthcare systems are complex and changing entities, thereby shifting focus towards the healthcare organisation's resilient and adaptive capacities. Based on a close reading of predominant patient safety literature, the article analyses how a separation between stability and change is articulated in ontological, historical, and situated terms, and it suggests the way in which predetermining healthcare settings as either stable or unstable paves the way for a system engineering approach to patient safety that pre‐empts certain types of safety solutions. Drawing on John Dewey's influential ideas about the interconnectedness of stability and change, this prescriptive perspective is discussed and challenged. It is suggested that only by rethinking the relationship between change and stability can patient safety efforts begin to address the uncertainty of medical practice as well as the necessary competences of healthcare professionals to act with ‘safety dispositions’ as a precondition for delivering safe care.