There is a growing national consensus that employing institutional measures of control, such as isolation, restraint, chemical restraint, and handcuffed transport, within psychiatric hospitals is far too prevalent and may be counter-therapeutic. Unfortunately, nothing is known about how to eliminate these last-resort methods. Research on patient safety in mental health has lagged in the adoption of a system perspective and approach. However, recognizing that no single factor or group of factors accounts for a patient safety incident, in light of the paucity of data, we describe factors, standards, and procedures that may contribute to adverse events in mental health. Methods: PubMed and Psych info were searched to locate studies that specifically evaluated efforts to reduce seclusion and restraint in psychiatric units. Key search terms included seclusion, restraint, reduce, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry. Based on this search, little is known about how to reduce such measures of last resort and improve the safety of psychiatric settings. The review of the available literature found a few descriptions of administrative efforts to reduce seclusion and restraint at specific psychiatric hospitals or units that were followed by limited objective documentation of fewer episodes of seclusion or restraint. Conclusions: Hopefully, this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in the psychiatric setting.