Patient Safety: What Is Working and Why?

  • Thomas BartmanEmail author
  • C. Briana Bertoni
  • Jenna Merandi
  • Michael Brady
  • Ryan S. Bode
Patient Safety (M Scanlon, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Patient Safety


Purpose of review

Our goal is to review a number of methodologies which have been used to improve safety in healthcare since the release of the Institute of Medicine report in 1998 which documented that error was a significant cause of mortality in the USA.

Recent findings

Multifaceted approaches have each led to reduction in error. Methods for error reduction included in this review are “Just Culture,” increased transparency and accountability, error reporting and investigation, second-victim programs, training in quality and safety methods, standardization and bundles, electronic health records, computerized order entry, barcode scanning, clinical decision support, predictive analytics, and situational awareness. Newer fields with the potential to improve patient safety include human factors engineering, indication-based prescribing, and Safety II.


While each intervention has led to incremental improvement, continued expansion of these programs is necessary to eliminate medical error.


Patient safety Culture Event reporting Electronic health record Quality improvement Standardization 



Institute of Medicine


Adverse drug event


Quality improvement


Healthcare acquired infection


Central line-associated bloodstream infection


Surgical site infection


Catheter-associated urinary tract infection


Ventilator-associated pneumonia


Centers for Disease Control


Electronic health record


Health information technology


Computerized physician order entry


Health Information Technology for Economic and Clinical Health


Health Insurance Portability and Accountability Act


Clinical decision support


Intensive care unit


Rapid response team


Pediatric Early Warning Score


Human factors engineering


Systems Engineering Initiative for Patient Safety


Institute for Safe Medication Practices


Work as done


Work as imagined


Compliance with Ethical Standards

Conflict of Interest

Thomas Bartman, declares that he has no conflict of interest. C. Briana Bertoni declares that she has no conflict of interest. Jenna Merandi declares that she has no conflict of interest. Michael Brady declares that he has no conflict of interest. Ryan S. Bode declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Thomas Bartman
    • 1
    • 2
    Email author
  • C. Briana Bertoni
    • 3
  • Jenna Merandi
    • 4
  • Michael Brady
    • 2
    • 5
  • Ryan S. Bode
    • 2
    • 6
  1. 1.Quality Improvement ServicesNationwide Children’s HospitalColumbusUSA
  2. 2.Department of PediatricsThe Ohio State University College of MedicineColumbusUSA
  3. 3.Clinical Fellowship in Quality and Safety LeadershipNationwide Children’s HospitalColumbusUSA
  4. 4.Nationwide Children’s HospitalColumbusUSA
  5. 5.Patient SafetyNationwide Children’s HospitalColumbusUSA
  6. 6.Hospital MedicineNationwide Children’s HospitalColumbusUSA

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