Virginia Mason and Kaiser Permanente, which provide both outpatient doctor visits and in-hospital care, have integrated their CPOE systems with electronic medical record keeping, so new drug orders can be checked against the patient's existing medication record for possible interactions and allergies. When a patient leaves the hospital, the system updates his or her medication list.

Virginia Mason also takes the unusual step of tracking medications prescribed outside the hospital — staff can learn if a patient has actually filled a prescription. That could change the treatment if the hospital staff notices that a patient admitted with high blood pressure, for instance, hasn't been filling prescriptions.

Infection control

Five to 10 percent of patients get a preventable infection in the hospital, and nearly 100,000 people die from one each year, reports the Centers for Disease Control and Prevention. To avert these tragedies, today's safest hospitals rely on checklists, such as those used by airline pilots. One such checklist, developed by Peter J. Pronovost, M.D., senior vice president for patient safety and quality at the Johns Hopkins Medical Center in Baltimore, has been tremendously successful in reducing central line infections, which occur when a catheter used to provide a patient with medicine or nourishment becomes contaminated.

Up to 20,000 patients die each year from central line infections, according to an article in the journal Emerging Infectious Diseases. When the University of Michigan Hospitals and Health Centers introduced Pronovost's five-item checklist — which includes such practical steps as washing your hands and cleaning patients' skin before inserting a line — it was able to reduce central line infections by 66 percent.

Several years ago Brigham and Women's Hospital in Boston started a prevention protocol against C. difficile —a cause of infectious diarrhea in hospitals — featuring prominent door signs for affected patients, while also stepping up its C. difficile treatment regimen. The result: Incidence rates have dropped by 40 percent.

And The Methodist Hospital in Houston uses an electronic screening tool to pick up early signs of sepsis — a severe blood infection that kills more than 230,000 people annually.

Surgical errors

Before every surgery at Regions Hospital in St. Paul, Minnesota, the flurry of pre-op activity stops and team members who are preparing to spend the next few hours together gather around the patient for a time-out: an opportunity to introduce themselves to one another.

The team verifies the patient's name, the type of surgery and the surgical site, using a checklist with each of these steps blown up in giant letters so everyone can see them. "We make it easier for providers to do the right thing," says Beth Heinz, the hospital's chief quality officer. The hospital also places a sterile "time-out towel" over the surgical instruments, to act as a visible cue to perform this important step. Says Heinz, "You can't touch the instruments without that reminder to do the time-out."

Such "time-outs" are routine among the hospital-safety superstars. "Anonymity is not safe in the OR," says Marty Makary, M.D., author of Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care. He maintains that it tends to reduce accountability, which in turn can "promote harmful behavior."

Surgeons at Montefiore Medical Center in the Bronx, New York, supplement manual counts of surgical tools with a technology that tags surgical sponges with radio frequency chips. Before closing up a patient, the surgeon waves a wand over the body to locate missing sponges. "Sponges soaked in blood or fluid can be hard to spot inside a body cavity," says Robert E. Michler, M.D., Montefiore's surgeon in chief. The system allows surgeons to work more efficiently, avoiding X-rays and getting the patient into recovery more quickly.

ICU safety

At Virginia Mason, gone are the days when a patient stops breathing and everyone comes running, creating mass confusion. Now key responders have designated roles and stand at specific places around the bed of a patient in crisis. In addition, the hospital conducts code drills to fine-tune performance. "Every time we drill, we find a place to improve," says Ian Smith, M.D., head of the hospital's critical-care unit and respiratory therapy and one of its 12 "intensivists," doctors trained to manage the complex care needs of critically ill patients.

Only about 35 percent of hospitals that responded to a Leapfrog survey had intensivists monitor every patient in the ICU. Yet doing so reduces the risk of death in critical-care units by up to 40 percent, according to Leapfrog.

At night, when many ICUs are staffed solely by nurses, hospitals such as Lehigh Valley rely on remote monitoring by intensivists from a command center a few miles away. "Our system provides both audio and visual access in room," says Lehigh Valley's Ardire. "The picture is so clear you can examine the pupils of the patient's eyes."

Nursing quality

In the years before Virginia Mason's safety crusade, nurses scrambled for supplies, sometimes waiting in line at a medication vending machine or even running down the street to get supplies at a drugstore. At shift changes, they gathered in a conference room to discuss patients, leaving them unattended for up to an hour, says Charleen Tachibana, RN, chief nursing officer.

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