Hospital Safety Rankings: What San Diego Patients Need to Know

These Are San Diego County's Safest, And Least Safe, Hospitals: New Leapfrog Ranking | San Diego, CA Patch

When choosing a hospital, patients and families typically focus on location, insurance coverage, and physician recommendations. But a crucial factor often overlooked is patient safety—the likelihood of experiencing preventable harm during a hospital stay. New data from The Leapfrog Group's Fall 2025 Hospital Safety Grades reveals significant variations in safety performance across San Diego County hospitals, raising important questions about how patients can protect themselves when seeking medical care.

Understanding Hospital Safety Metrics

Medical errors, infections, and preventable complications remain stubbornly persistent problems in American healthcare. Research indicates that these largely preventable issues harm approximately one in four hospital inpatients and may contribute to as many as 250,000 deaths annually. These figures have made hospital safety assessment a critical consumer concern.

The Leapfrog Group, an independent watchdog organization founded 25 years ago, evaluates hospitals nationwide based on their ability to protect patients from medical errors, accidents, injuries, and infections. Their biannual Safety Grade assigns letter grades from A to F to general hospitals across the United States. The methodology examines dozens of measures of hospital safety, including infection rates, staffing levels, surgical outcomes, and adherence to safety protocols.

San Diego County's Safety Landscape

San Diego County's hospital safety profile shows strong overall performance: 12 hospitals earned an A grade, six received a B, and one received a C, with no hospitals receiving D or F grades. This distribution suggests the region's healthcare facilities generally maintain above-average safety standards compared to national patterns.

Particularly notable are the six San Diego-area hospitals designated as "Straight A" facilities—institutions that have maintained A grades for more than two consecutive years. These consistent high performers include Kaiser Permanente San Diego Medical Center, Paradise Valley Hospital in National City, Scripps Green Hospital in La Jolla, Scripps Memorial Hospital of Encinitas, Sharp Grossmont Hospital in La Mesa, and UC San Diego Health La Jolla's Jacobs Medical Center and Sulpizio Cardiovascular Center.

The single C-rated facility in the county was Tri-City Medical Center in Oceanside, indicating room for improvement in safety protocols and outcomes at that institution.

The Health System Advantage

The Fall 2025 report marks the first time Leapfrog has systematically analyzed whether hospitals affiliated with larger health systems demonstrate different safety performance than independent facilities. The analysis found that 90 percent of graded hospitals belong to health systems, with A-rated hospitals showing a slightly higher affiliation rate at 94 percent.

This correlation suggests potential advantages of system membership, including standardized safety protocols, shared best practices, coordinated quality improvement initiatives, and greater resources for safety technology and training. Among the 358 hospitals nationwide earning the Straight A designation, 95 percent are part of health systems. Most tellingly, all 11 hospitals that have earned an A grade in every rating period since 2012 are system-affiliated.

However, system membership alone doesn't guarantee superior safety. The report identifies wide variations in performance even within the same health system, underscoring that institutional culture, leadership commitment, and local execution remain critical factors.

What These Grades Mean for Patients

Hospital safety grades should factor prominently in healthcare decisions, particularly for planned procedures where patients have choice in facility selection. The differences between A-rated and C-rated hospitals can translate into measurably different risks of infection, medication errors, falls, pressure ulcers, and other preventable complications.

However, consumers should understand these grades represent broad assessments across multiple safety domains. A hospital's overall grade may not reflect its performance in specific areas relevant to a patient's particular needs. For instance, a facility might excel in cardiac surgery safety while showing weaknesses in infection control, or vice versa.

Patients preparing for hospitalization should consider several protective strategies regardless of facility grade:

Research specific procedures: Beyond overall safety grades, investigate a hospital's track record with your specific procedure or condition. Leapfrog and other sources provide procedure-specific data.

Ask about infection rates: Surgical site infections and catheter-associated infections vary significantly between hospitals. Request specific data about infection rates for your planned procedure.

Verify staffing levels: Adequate nurse staffing correlates strongly with better patient outcomes. Ask about nurse-to-patient ratios on the units where you'll receive care.

Understand handoff protocols: Communication breakdowns during shift changes and patient transfers cause many preventable errors. Inquire about standardized handoff procedures.

Engage a patient advocate: Having a family member or friend present during hospitalization helps catch errors and ensures continuity of information across care teams.

Speak up about concerns: Patients and families should feel empowered to question medications, procedures, and care decisions that seem inconsistent with previous information.

Limitations and Controversies

Hospital safety grading systems face ongoing methodological debates. Critics note that grading methodologies may disadvantage hospitals serving more complex patient populations or those with greater transparency in reporting adverse events. Teaching hospitals, which often care for the sickest patients, sometimes argue that risk-adjustment formulas don't fully account for patient complexity.

Additionally, the voluntary nature of some data reporting means hospitals can choose what information to share, potentially skewing comparative assessments. However, Leapfrog has increasingly incorporated mandatory public reporting data, reducing opportunities for selective disclosure.

The relative weight given to different safety measures also generates discussion. Some argue infection rates deserve greater emphasis, while others prioritize process measures like medication reconciliation protocols or staffing ratios.

The Broader Context

San Diego County's strong safety performance reflects both regional healthcare quality and California's aggressive patient safety regulations. The state has implemented some of the nation's strictest nurse staffing requirements, mandatory infection reporting, and hospital safety standards—policies that correlate with improved patient outcomes.

California tied for sixth nationally in the percentage of hospitals earning A grades, suggesting the state's regulatory environment may contribute to above-average safety performance.

Nationally, geographic variation in hospital safety remains substantial, with four states—Iowa, North Dakota, Vermont, and Wyoming—having no A-rated hospitals in the Fall 2025 report. This disparity highlights how healthcare quality continues to depend heavily on where patients happen to live.

Making Informed Choices

Hospital safety grades provide valuable, accessible information for healthcare consumers navigating complex medical decisions. While no grading system captures every dimension of hospital quality, and while even A-rated hospitals experience preventable complications, these assessments offer evidence-based guidance for patients seeking to minimize risk.

San Diego County residents benefit from multiple high-performing hospital options across different geographic areas and specialties. Patients should use safety grades as one important factor in hospital selection, alongside considerations like physician expertise, insurance networks, specialized capabilities, and location.

As Leapfrog president and CEO Leah Binder noted when discussing the organization's expanded focus on health system performance, understanding whether institutional structure and leadership accelerate or impede patient safety remains crucial for driving improvement across American healthcare.

The ultimate goal extends beyond grading hospitals to creating systems where preventable harm becomes genuinely rare. Until that goal is achieved, informed patients must actively engage in protecting their own safety during hospitalization, using available information to make the best possible choices among available options.

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Sources

1. Houck, K. (2025, November). These Are San Diego County's Safest, And Least Safe, Hospitals: New Leapfrog Ranking. Patch. Retrieved from https://patch.com/california/san-diego/these-are-san-diego-countys-safest-least-safe-hospitals-new-leapfrog-ranking

2. The Leapfrog Group. (2025). Fall 2025 Hospital Safety Grades. https://www.hospitalsafetygrade.org/

3. James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), 122-128. https://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx

4. Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139. https://www.bmj.com/content/353/bmj.i2139

5. Agency for Healthcare Research and Quality. (2024). Hospital Survey on Patient Safety Culture. U.S. Department of Health and Human Services. https://www.ahrq.gov/sops/surveys/hospital/index.html

6. Aiken, L. H., Sloane, D. M., Barnes, H., Cimiotti, J. P., Jarrín, O. F., & McHugh, M. D. (2018). Nurses' and Patients' Appraisals Show Patient Safety in Hospitals Remains a Concern. Health Affairs, 37(11), 1744-1751. https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0711

7. California Department of Public Health. (2024). Healthcare-Associated Infections in California Hospitals Annual Report. https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/AnnualHAIReports.aspx

8. Centers for Medicare & Medicaid Services. (2025). Hospital Compare. https://www.medicare.gov/care-compare/

9. Landrigan, C. P., Parry, G. J., Bones, C. B., Hackbarth, A. D., Goldmann, D. A., & Sharek, P. J. (2010). Temporal Trends in Rates of Patient Harm Resulting from Medical Care. New England Journal of Medicine, 363(22), 2124-2134. https://www.nejm.org/doi/full/10.1056/NEJMsa1004404

10. The Joint Commission. (2024). National Patient Safety Goals. https://www.jointcommission.org/standards/national-patient-safety-goals/

Sidebar 1: San Diego County's Straight A Hospitals

Consistent Excellence in Patient Safety

Six hospitals in San Diego County have earned the prestigious "Straight A" designation, meaning they have maintained A grades for more than two consecutive years. These facilities demonstrate sustained commitment to patient safety protocols and consistently superior performance:

• Kaiser Permanente San Diego Medical Center San Diego System: Kaiser Permanente (Oakland, CA)
• Paradise Valley Hospital National City Independent/Regional System
• Scripps Green Hospital La Jolla System: Scripps Health
• Scripps Memorial Hospital of Encinitas Encinitas System: Scripps Health
• Sharp Grossmont Hospital La Mesa System: Sharp HealthCare
• UC San Diego Health La Jolla - Jacobs Medical Center and Sulpizio Cardiovascular Center La Jolla System: UC San Diego Health

These institutions represent diverse organizational structures—from Kaiser's integrated managed care model to academic medical centers like UC San Diego Health—demonstrating that multiple approaches can achieve consistently high safety performance.

Nationally, only 358 hospitals earned Straight A status in Fall 2025, representing approximately 13% of all graded hospitals. Just 11 hospitals nationwide have maintained A grades in every rating period since Leapfrog began biannual grading in 2012—all of them affiliated with health systems.

Patients seeking elective procedures or planned admissions in San Diego County may want to prioritize these facilities, as sustained high performance suggests deeply embedded safety cultures rather than temporary improvements.

San Diego County Hospitals: Areas for Improvement

While San Diego County's overall hospital safety performance is strong, 13 facilities did not achieve the Straight A designation. Understanding where these hospitals fell short requires examining publicly available data, though Leapfrog does not release comprehensive detailed performance metrics for individual hospitals without their consent.

Hospitals Receiving A Grades (But Not Straight A)

These six hospitals earned A grades in Fall 2025 but have not maintained that performance consistently over multiple rating periods:

Kaiser Permanente Zion Medical Center, San Diego

Grade: A (Fall 2025)

This Kaiser facility earned an A grade but lacks the sustained multi-year track record required for Straight A status. As a newer addition to grading or a facility with previous B-grade performance, it shows current excellence but hasn't yet demonstrated the consistent two-year-plus record needed.

Likely improvement area: Achieving consistency across all rating periods to join its sister facility (Kaiser San Diego Medical Center) in the Straight A category.

Naval Medical Center San Diego, San Diego

Grade: A (Fall 2025)

The Leapfrog report notes that military hospitals under the Defense Health Agency haven't been eligible for Safety Grades long enough (less than five rounds) to qualify for Straight A status, even with perfect performance. Naval Medical Center San Diego will become eligible for Straight A consideration in 2026.

Note: This is a structural limitation, not a performance issue. The facility's A grade suggests strong safety performance, but the military hospital system's later entry into Leapfrog grading creates a waiting period.

Palomar Medical Center Escondido, Escondido

Grade: A (Fall 2025)

Palomar Escondido earned an A but hasn't maintained this level consistently across rating periods. Without access to previous grades, possible areas of previous weakness could include:

Potential improvement areas based on common challenges for hospitals achieving A grades inconsistently:

• Healthcare-associated infection rates that fluctuate between rating periods
• Process measure compliance (CPOE, bar code medication administration)
• Specific patient safety indicators showing periodic spikes
• Staffing metrics during periods of nursing shortages

Scripps Mercy Hospital of Chula Vista, Chula Vista

Grade: A (Fall 2025)

Potential considerations: Scripps Mercy Chula Vista serves a diverse, lower-income population compared to some other Scripps facilities, which can present challenges in achieving sustained top grades due to:

• Higher rates of chronic disease and comorbidities requiring risk adjustment
• Language barriers potentially affecting communication and safety
• Social determinants of health affecting readmissions and outcomes

Scripps Mercy Hospital of San Diego, San Diego

Grade: A (Fall 2025)

Like its Chula Vista sister facility, Scripps Mercy San Diego provides significant charity care and serves vulnerable populations. As a Level I trauma center, it also treats severely injured patients whose complexity may affect some safety metrics despite excellent care.

Possible historical challenges:

• Trauma patient complexity affecting mortality metrics
• Urban location serving higher-risk populations
• Variation in specific infection metrics or surgical complications

UC San Diego Health East Campus - East Campus Medical Center, San Diego

Grade: A (Fall 2025)

As a newer facility (opened in recent years), East Campus may not have sufficient grading history to achieve Straight A status, or may have had initial adjustment periods affecting earlier grades.

Likely scenario: New facility still building track record, similar to Kaiser Zion.

Hospitals Receiving B Grades

Six hospitals earned B grades, indicating generally good safety performance with identifiable areas needing improvement:

Palomar Medical Center Poway, Poway

Grade: B

Notable contrast: Palomar Escondido (the system's flagship) earned an A, while Poway earned a B, suggesting systematic differences between the two facilities.

Possible weakness areas:

• Lower procedure volumes: Smaller facilities often struggle with certain metrics due to lower procedure volumes affecting statistical reliability
• Staffing differences: May have different nurse-to-patient ratios or physician coverage models
• Specific infection rates: Possible higher rates in one or more HAI categories
• Surgical complication rates: Fewer complex procedures but possibly higher complication rates for procedures performed

Scripps Memorial Hospital of La Jolla, La Jolla

Grade: B

Significant note: This B-grade is surprising given that Scripps Green Hospital (also in La Jolla, same health system) earned Straight A status.

Possible differentiating factors:

• Patient population differences: Memorial La Jolla may serve different demographics or case mix than Green
• Facility age and infrastructure: Older facility may have environmental or structural challenges
• Service line differences: Different specialties and complexity of cases
• Specific metric underperformance: Likely weaker performance in 2-3 specific categories bringing down overall grade

Most likely weakness areas based on B-grade performance:

• One or more healthcare-associated infection categories with SIR >1.0
• Specific patient safety indicators (falls, pressure ulcers, surgical complications)
• Possible gaps in process measures (CPOE compliance, ICU staffing, medication safety systems)

Sharp Chula Vista Medical Center, Chula Vista

Grade: B

Contrast within system: Sharp Grossmont earned Straight A status, indicating system-wide protocols alone don't guarantee top performance.

Possible contributing factors:

• Community demographics: Serves South Bay area with different socioeconomic profile than some other Sharp facilities
• Facility size and resources: May have fewer resources than flagship Sharp Memorial
• Specific clinical weaknesses: Likely underperformance in particular service lines or infection categories

Common B-grade weaknesses:

• Surgical site infection rates above benchmark for specific procedures
• CAUTI or CLABSI rates exceeding targets
• Specific PSI indicators (postoperative complications, falls, pressure ulcers)
• Mortality metrics in one or more measured conditions

Sharp Coronado Hospital and Healthcare Center, Coronado

Grade: B

Context: Small community hospital serving Coronado and surrounding areas.

Likely challenges for small hospitals:

• Volume limitations: Low volumes in measured procedures create statistical volatility
• Resource constraints: Smaller facilities may lack specialized expertise in all measured areas
• Referral patterns: May transfer more complex patients, but still measured on outcomes
• Staffing models: May use different staffing approaches than larger facilities

Probable specific weaknesses:

• Process measures where small hospitals often struggle (24/7 intensivist coverage in ICU, certain technology implementations)
• Possible higher complication rates in lower-volume procedures
• One or more infection categories with elevated rates

Sharp Memorial Hospital, San Diego

Grade: B

Most surprising B-grade: As Sharp HealthCare's flagship hospital and a major regional medical center, this B-grade stands in notable contrast to Sharp Grossmont's Straight A performance.

Possible explanations:

• Teaching hospital factors: As a training facility, may have resident involvement affecting some metrics
• Case complexity: Serves as regional referral center for most complex cases
• Service line breadth: Comprehensive services may include some lower-performing areas
• Urban trauma center: Level II trauma designation brings high-risk patients

Likely specific weaknesses causing B grade:

• Healthcare-associated infections: One or more categories (CLABSI, CAUTI, SSI, MRSA, C. diff) with SIR >1.0
• Surgical complications: Possible higher rates in complex procedures despite appropriate risk adjustment
• Specific PSI indicators: Falls, pressure ulcers, postoperative complications
• Mortality metrics: Possible higher-than-expected mortality in one or more measured conditions

Most probable issue: Given Sharp's strong system-wide protocols, the B-grade likely reflects 1-2 specific problem areas rather than broad deficiencies—possibly ICU-related infections or complications in a specific surgical service line.

UC San Diego Health Hillcrest - Hillcrest Medical Center, San Diego

Grade: B

Significant contrast: Within UC San Diego Health system, Jacobs Medical Center/Sulpizio Cardiovascular Center earned Straight A, while Hillcrest earned B.

Context factors:

• Facility age: Hillcrest is the older, legacy campus
• Patient population: May handle different case mix than newer Jacobs facility
• Service distribution: Different specialties concentrated at different campuses
• Infrastructure differences: Older buildings may present infection control challenges (room configuration, ventilation, isolation capacity)

Academic medical center challenges:

• Teaching environment: Resident and fellow involvement in care
• Research protocols: Patient participation in clinical trials may affect some metrics
• Referral complexity: Tertiary care center receiving most difficult cases
• Organ transplantation: Immunosuppressed patients at higher infection risk

Likely specific weaknesses:

• Healthcare-associated infections: Possibly elevated rates in immunocompromised populations (transplant, oncology)
• C. difficile infections: Common challenge in academic centers with heavy antibiotic use
• ICU-related complications: Complex ICU patients may have higher complication rates
• Specific surgical complications: Certain high-risk procedures may have elevated complication rates

The C-Grade Facility

Tri-City Medical Center, Oceanside

Grade: C

Tri-City's C grade indicates substantial safety concerns requiring urgent attention. This is the only hospital in San Diego County falling below B-grade performance.

Context:

• Independent, not-for-profit community hospital
• Not part of a larger health system (unlike most higher-performing facilities)
• Serves North County coastal communities
• 390-bed facility providing comprehensive services

Typical areas of weakness for C-grade hospitals:

Healthcare-Associated Infections (Likely Major Issue):

• Multiple infection categories with SIR substantially above 1.0
• Possible deficiencies in infection prevention practices:
  • Hand hygiene compliance
  • Environmental cleaning and disinfection
  • Device insertion and maintenance protocols
  • Antibiotic stewardship

Patient Safety Indicators (Probable Problems):

• Elevated rates of preventable complications:
  • Pressure ulcers
  • Falls with injury
  • Postoperative complications (sepsis, respiratory failure, wound problems)
  • Perioperative hemorrhage or blood clots

Process/Structural Measures (Possible Gaps):

• Incomplete implementation of safety technologies (CPOE, barcode medication administration)
• Inadequate ICU physician staffing
• Gaps in medication safety protocols
• Lower nurse staffing ratios

Mortality Metrics (Likely Elevated):

• Higher-than-expected death rates for one or more conditions
• Observed-to-expected mortality ratio >1.0

Organizational Factors:

• Independent status: Lacks large system resources for best practice sharing, technology investment, safety infrastructure
• Financial pressures: Community hospitals often face tighter margins limiting safety investments
• Staffing challenges: May struggle to recruit and retain experienced nurses and specialists
• Quality infrastructure: May have less robust quality/safety departments than system-affiliated hospitals

What C-grade means for patients:

Patients requiring emergency care at Tri-City should receive it, as transport delays create their own risks. However, for elective procedures, patients should seriously consider:

• Choosing an A-rated facility for planned surgeries
• Asking specific questions about infection rates for their planned procedure
• Requesting detailed safety data before proceeding
• Understanding that C-grade indicates measurably higher risk of preventable complications

Path to improvement:

Tri-City can improve its grade through:

• Systematic implementation of evidence-based infection prevention bundles
• Investment in safety technology and infrastructure
• Enhanced quality improvement processes with regular measurement and feedback
• Improved nurse staffing and retention
• Potential system affiliation or partnership for resource sharing
• Leadership commitment to safety culture transformation

Important Limitations

Data constraints: Without access to hospital-specific detailed performance data, the weakness areas identified above are informed estimates based on:

• Common patterns in hospitals receiving similar grades
• Published research on factors distinguishing grade levels
• Known characteristics of the facilities (size, teaching status, patient population)
• General Leapfrog methodology and measure weighting

Actual weaknesses: Individual hospitals may have different specific issues than those suggested here. Patients should:

• Request specific performance data directly from hospitals
• Review detailed information on Leapfrog's website (some hospitals share additional detail)
• Ask surgeons and physicians about safety performance for specific procedures
• Consider multiple factors beyond overall letter grade

Context matters: Some lower grades may reflect:

• Serving higher-risk populations despite good care quality
• Statistical variation in small-volume procedures
• Emphasis on access and community service over selective patient acceptance
• Recent quality improvement transitions that haven't yet impacted metrics

Recommendations for Patients

For elective procedures:

• Prioritize Straight A hospitals when feasible
• If choosing A-rated (non-Straight A) or B-rated facilities, ask about specific performance in your procedure category
• Seriously consider alternatives to C-rated facilities for planned surgeries

For emergency situations:

• Accept care at nearest appropriate facility regardless of grade
• Transfer for ongoing care to higher-graded facility when medically stable

Questions to ask any hospital:

• "What is your specific infection rate for my planned procedure?"
• "How does your performance on [specific concern] compare to benchmarks?"
• "What quality improvement initiatives are you implementing?"
• "Can you share your detailed Leapfrog performance data?"

System considerations: Sharp HealthCare, Scripps Health, and UC San Diego Health all have facilities spanning multiple grade levels, demonstrating that system affiliation alone doesn't guarantee top performance. Individual facility selection matters significantly within systems.

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Additional Sources

26. The Leapfrog Group. (2025). Individual Hospital Safety Grade Reports. https://www.hospitalsafetygrade.org/

27. Agency for Healthcare Research and Quality. (2023). Patient Safety Network: Hospital Survey on Patient Safety Culture Comparative Database. https://www.ahrq.gov/sops/surveys/hospital/index.html

28. Jha, A. K., Orav, E. J., Epstein, A. M. (2010). Low-Quality, High-Cost Hospitals, Mainly In South, Care For Sharply Higher Shares Of Elderly Black, Hispanic, And Medicaid Patients. Health Affairs, 29(10), 1904-1911. https://www.healthaffairs.org/doi/10.1377/hlthaff.2010.0027

29. McHugh, M. D., Berez, J., Small, D. S. (2013). Hospitals With Higher Nurse Staffing Had Lower Odds Of Readmissions Penalties Than Hospitals With Lower Staffing. Health Affairs, 32(10), 1740-1747. https://www.healthaffairs.org/doi/10.1377/hlthaff.2013.0613

 

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Sidebar 2: Understanding Leapfrog's Grading Methodology

How Hospitals Earn Their Safety Grades

The Leapfrog Hospital Safety Grade employs a comprehensive, evidence-based methodology that evaluates approximately 30 performance measures across multiple domains of patient safety. Understanding what goes into these grades helps patients interpret their significance.

Data Sources

Leapfrog draws from multiple authoritative databases:

Centers for Medicare & Medicaid Services (CMS): Hospital Compare data, including complications, readmissions, and mortality metrics for Medicare patients

Agency for Healthcare Research and Quality (AHRQ): Patient Safety Indicators (PSIs), which use administrative data to identify potentially preventable adverse events

Leapfrog Hospital Survey: Voluntary reporting by hospitals on structural measures like staffing, medication safety systems, and adherence to protocols

CDC National Healthcare Safety Network (NHSN): Healthcare-associated infection rates, including central line infections, surgical site infections, catheter-associated urinary tract infections, and C. difficile infections

American College of Surgeons: Surgical quality data for participating hospitals

Major Grading Categories

Process/Structural Measures (Weight: ~30%)

• Computerized physician order entry (CPOE) for medications
• ICU physician staffing (intensivist presence)
• Bar code medication administration
• Safe medication administration practices
• Hand hygiene compliance

Outcome Measures (Weight: ~70%)

• Healthcare-associated infections (HAIs)
• Surgical complications and mortality
• Medical errors and adverse events
• Risk-adjusted mortality rates
• Patient safety indicators

Medical Error and Iatrogenic Incident Measurement

Leapfrog relies heavily on AHRQ Patient Safety Indicators (PSIs), which use administrative discharge data to identify potential medical errors and complications:

• PSI-03: Pressure ulcers (bedsores) developing during hospitalization  
• PSI-06: Iatrogenic pneumothorax (collapsed lung from medical procedure)  
• PSI-08: In-hospital fall with hip fracture  
• PSI-09: Perioperative hemorrhage or hematoma  
• PSI-10: Postoperative acute kidney injury  
• PSI-11: Postoperative respiratory failure  
• PSI-12: Perioperative pulmonary embolism or deep vein thrombosis  
• PSI-13: Postoperative sepsis  
• PSI-14: Postoperative wound dehiscence (surgical wound splitting open)  
• PSI-15: Accidental puncture or laceration during procedure  
• PSI-90: Patient Safety and Adverse Events Composite

These indicators use ICD diagnostic codes to identify complications that likely represent medical errors or preventable harm, with statistical risk adjustment for patient characteristics and comorbidities.

Mortality Measurement

Leapfrog incorporates several mortality metrics:

CMS Hospital-Wide All-Cause Mortality: Risk-adjusted death rates across all hospitalized Medicare patients, accounting for age, severity of illness, and comorbidities

Surgical Mortality: Death rates following specific procedures, risk-adjusted for patient factors

Condition-Specific Mortality: Death rates for patients with heart attack, heart failure, pneumonia, COPD, and stroke

Observed-to-Expected Ratios: Compares actual deaths to predicted deaths based on patient risk profiles; ratios above 1.0 indicate worse-than-expected performance

Specialty-Specific Variations

Leapfrog's methodology does incorporate specialty considerations, though not through separate specialty-specific grades:

Surgical Specialties: The grading includes procedure-specific complication rates for:

• Abdominal aortic aneurysm repair
• Coronary artery bypass grafting (CABG)
• Bariatric surgery
• Pancreatectomy
• Esophagectomy
• Other complex surgeries

Maternity Care: Separate measures evaluate C-section rates, early elective deliveries, and episiotomy use

Critical Care: ICU physician staffing measures specifically address intensive care unit safety

Oncology and Radiation: These specialties are not directly addressed through specialty-specific measures, though oncology patients would be included in general comorbidity risk adjustment, and complications from radiation or chemotherapy toxicity could appear in PSIs like postoperative sepsis or acute kidney injury

Cardiology: Cardiac-specific measures include surgical outcomes for CABG, as well as mortality rates for heart attack and heart failure patients

Limitations by Specialty

Cancer Centers: May be disadvantaged in mortality metrics, as they treat patients with terminal conditions where death is expected rather than preventable

Transplant Programs: Complex immunosuppressed patients face higher baseline complication risks that risk adjustment may not fully capture

Level I Trauma Centers: Treating the most severely injured patients can elevate complication and mortality rates despite excellent care

Pediatric Hospitals: Children's hospitals receive separate grading due to fundamentally different patient populations and risk profiles

Statistical Methodology

Leapfrog employs sophisticated statistical approaches:

• Risk adjustment: Controls for patient age, severity of illness, comorbidities, and socioeconomic factors
• Latent variable modeling: Identifies underlying patterns across multiple related measures
• Reliability weighting: Gives more weight to measures based on larger patient samples
• National benchmarking: Compares each hospital to national performance distributions

The final grade represents a composite score converted to letter grades, with approximately:

• Top 31% receiving A grades
• Next 27% receiving B grades
• Middle 35% receiving C grades
• Bottom 7% receiving D or F grades

Updating and Transparency

Leapfrog updates Safety Grades twice annually (spring and fall), incorporating the most recent available data. The complete methodology is publicly available at www.hospitalsafetygrade.org, allowing hospitals and consumers to understand exactly what drives the grades.

Critics note that the methodology may not fully capture important dimensions like patient experience, appropriateness of care, or long-term outcomes beyond hospitalization. Additionally, voluntary survey participation means some hospitals may not report all requested data, though Leapfrog has increasingly shifted toward mandatory public reporting sources.

Nevertheless, the Leapfrog Safety Grade remains one of the most comprehensive, publicly accessible hospital safety assessments available to American healthcare consumers.

The Hidden Epidemic: Infections Generated During Care

Healthcare-associated infections (HAIs) represent one of the most significant—and most preventable—categories of hospital harm. These infections, which patients acquire during the course of receiving medical treatment, factor heavily into Leapfrog's Safety Grades and deserve particular attention from consumers evaluating hospital safety.

The Scope of the Problem

Each year, approximately 1.7 million healthcare-associated infections occur in U.S. hospitals, contributing to an estimated 99,000 deaths. These infections add between $28 billion and $45 billion in healthcare costs annually. What makes HAIs particularly troubling is that evidence-based interventions can prevent 50-70% of these infections, yet implementation remains inconsistent across hospitals.

Types of HAIs Measured by Leapfrog

The Leapfrog Safety Grade incorporates infection data from the CDC's National Healthcare Safety Network (NHSN), which tracks several major categories:

Central Line-Associated Bloodstream Infections (CLABSI)

These serious infections occur when bacteria enter the bloodstream through central venous catheters—IV lines inserted into large veins in the chest, neck, or groin. CLABSIs carry mortality rates of 12-25% and represent one of the most deadly HAIs.

Leapfrog evaluates hospitals on their Standardized Infection Ratio (SIR)—the ratio of observed infections to predicted infections based on patient risk factors. An SIR below 1.0 indicates better-than-expected performance; above 1.0 indicates worse-than-expected performance.

Prevention measures include:

• Strict sterile technique during insertion
• Daily assessment of catheter necessity
• Chlorhexidine skin antisepsis
• Maximum sterile barriers during insertion
• Prompt removal when no longer essential

Catheter-Associated Urinary Tract Infections (CAUTI)

Urinary catheters cause approximately 75% of hospital-acquired urinary tract infections, making CAUTIs the most common type of HAI. While less lethal than bloodstream infections, CAUTIs cause significant morbidity, extend hospital stays, and can lead to secondary bloodstream infections.

Evidence-based prevention strategies include:

• Avoiding unnecessary catheter placement
• Proper insertion and maintenance techniques
• Daily review of catheter necessity
• Prompt removal using nurse-driven protocols
• Consideration of alternative bladder management methods

Surgical Site Infections (SSI)

These infections occur at or near the surgical incision within 30 days of the procedure (or up to 90 days for implant surgeries). SSIs complicate 2-5% of inpatient surgeries and account for 20% of all HAIs.

Leapfrog tracks SSIs for several high-risk procedures:

• Colon surgery
• Abdominal hysterectomy
• Coronary artery bypass graft (CABG)
• Hip and knee replacements (reported separately to CMS)

Prevention bundles include:

• Appropriate prophylactic antibiotic timing (within 60 minutes before incision)
• Proper antibiotic selection for specific procedures
• Antibiotic discontinuation within 24 hours post-surgery (48 hours for cardiac)
• Maintenance of perioperative normothermia (normal body temperature)
• Hair removal with clippers rather than razors
• Perioperative glucose control for diabetic patients
• Chlorhexidine-alcohol skin preparation

Methicillin-Resistant Staphylococcus Aureus (MRSA) Bloodstream Infections

MRSA represents a particularly dangerous category of antibiotic-resistant infections. Hospital-onset MRSA bloodstream infections indicate lapses in infection control, as MRSA spreads primarily through contact with contaminated hands, surfaces, or equipment.

Prevention focuses on:

• Hand hygiene compliance (target: >95% of opportunities)
• Contact precautions for colonized or infected patients
• Environmental cleaning and disinfection
• Active surveillance cultures in high-risk units (in some protocols)
• Decolonization protocols for surgical patients

Clostridioides difficile (C. diff) Infections

C. difficile causes severe, potentially life-threatening diarrhea, typically following antibiotic use that disrupts normal gut flora. Hospital-onset C. diff infections (symptoms beginning >3 days after admission) reflect both antibiotic stewardship and environmental hygiene practices.

C. difficile forms hardy spores that alcohol-based hand sanitizers cannot kill, requiring:

• Soap and water handwashing (not alcohol gel) when caring for infected patients
• Contact precautions with gown and gloves
• Bleach-based environmental disinfection
• Antibiotic stewardship programs to reduce unnecessary antibiotic use
• Extended precautions (until discharge or beyond)

How Infection Rates Affect Safety Grades

Healthcare-associated infection metrics carry substantial weight in Leapfrog's grading algorithm, typically accounting for 20-25% of the overall score. Hospitals receive individual scores for each infection type based on their Standardized Infection Ratios compared to national benchmarks.

The methodology recognizes that some patient populations face inherently higher infection risk:

• Immunocompromised patients (cancer, transplant, HIV/AIDS)
• Trauma and burn patients
• Patients requiring prolonged mechanical ventilation
• Those undergoing emergency rather than elective procedures
• Patients with diabetes, obesity, or chronic diseases

Statistical risk adjustment attempts to account for these factors, though debate continues about whether current models adequately capture case-mix complexity.

Variation Across San Diego Hospitals

While Leapfrog doesn't publicly release infection rates for individual hospitals (only overall grades), facilities can voluntarily report detailed infection data. The specific infection performance of San Diego hospitals likely varies considerably even among A-rated institutions.

Patients should consider requesting infection data directly from hospitals when planning elective procedures. Questions to ask include:

• "What is your hospital's SIR for central line infections in the ICU where I'll receive care?"
• "What percentage of your colon surgery patients develop surgical site infections?"
• "What is your MRSA bloodstream infection rate?"
• "How does your performance compare to state and national benchmarks?"

Under federal transparency requirements, hospitals must provide this information, though they may require formal requests.

Post-Operative Infections: Special Considerations

Surgical site infections deserve particular attention because they:

1. Vary dramatically by procedure type: Clean surgeries (no entry into gastrointestinal, respiratory, or genitourinary tracts) have infection rates of 1-2%, while contaminated surgeries may see rates of 10-20%

2. Depend on surgeon technique: Individual surgeon SSI rates can vary threefold even within the same hospital, though this data is rarely available to patients

3. Relate to hospital volume: High-volume centers performing specific procedures often achieve lower infection rates through experience and standardized protocols

4. May not manifest until after discharge: Many SSIs develop after patients leave the hospital, making surveillance challenging

5. Carry procedure-specific consequences: An infection after cardiac surgery with sternal wound involvement can be catastrophic, while a superficial infection after skin surgery may be minor

Leapfrog's surgical infection metrics focus on procedures where robust national data exists, but many operations lack standardized infection surveillance. For specialized surgeries, patients should specifically ask about infection rates for their planned procedure.

Ventilator-Associated Pneumonia: The Missing Metric

Notably absent from current Leapfrog grading is ventilator-associated pneumonia (VAP), despite it being a common and serious HAI. The CDC suspended VAP from mandatory reporting in 2013 due to surveillance challenges and definitional inconsistencies, shifting focus instead to ventilator-associated events (VAEs).

However, VAP remains clinically important, affecting 10-25% of mechanically ventilated patients and carrying mortality rates of 20-50%. Patients or families of loved ones requiring ventilator support should inquire about:

• VAP prevention protocols (head of bed elevation, oral care with chlorhexidine, sedation minimization, daily spontaneous breathing trials)
• Duration of ventilation (shorter is generally safer)
• ICU-specific infection rates

The Role of Antibiotic Stewardship

Inappropriate antibiotic use drives both C. difficile infections and the emergence of resistant organisms like MRSA and carbapenem-resistant Enterobacteriaceae (CRE). Leapfrog evaluates whether hospitals have formal antibiotic stewardship programs, which should include:

• Dedicated physician and pharmacist leadership
• Tracking of antibiotic resistance patterns
• Prospective audit and feedback on antibiotic prescribing
• Guidelines for appropriate antibiotic selection and duration
• Education programs for prescribers

Hospitals with robust stewardship programs typically achieve 15-30% reductions in inappropriate antibiotic use and corresponding decreases in C. difficile infections and antibiotic resistance.

Transparency and Accountability Gaps

Despite mandatory reporting requirements, significant gaps remain in infection surveillance:

Outpatient surgery centers: Not included in NHSN reporting, despite performing 60% of surgeries

Post-discharge infections: Many SSIs develop after hospital discharge, and follow-up surveillance varies widely

Device-associated infections in non-ICU settings: Most tracking focuses on intensive care units, with less rigorous surveillance on medical-surgical floors

Emerging resistant organisms: CRE and other highly resistant bacteria may not be systematically tracked

Environmental contamination: While hospitals track infection outcomes, routine environmental monitoring (surface contamination) isn't standardized

What Patients Can Do

Beyond choosing hospitals with strong overall safety grades, patients can take active steps to reduce infection risk:

Before admission:

• Optimize chronic conditions (glucose control for diabetics, smoking cessation)
• Consider chlorhexidine body washing before surgery (ask your surgeon)
• Ensure you're current on vaccinations
• For joint replacement, consider nasal decolonization if MRSA carrier

During hospitalization:

• Ensure all providers perform hand hygiene before touching you
• Request daily review of whether catheters and IV lines are still necessary
• Ask about appropriate antibiotic use if prescribed
• Keep surgical incisions clean and dry
• Request early mobilization and catheter removal

Advocate assertively:

• Don't hesitate to remind providers about hand hygiene
• Ask why devices are needed and when they'll be removed
• Question prolonged antibiotic courses
• Request isolation precautions be followed consistently

Research consistently shows that hospitals with strong safety cultures—where staff members feel empowered to speak up about safety concerns—achieve lower infection rates. Engaged, informed patients contribute to that culture.

The Bottom Line on Hospital Infections

Healthcare-associated infections represent a measurable difference between hospitals that can dramatically affect patient outcomes. A hospital's infection performance provides one of the clearest windows into its safety culture, attention to evidence-based protocols, and commitment to patient protection.

San Diego County's strong overall Leapfrog performance suggests most local hospitals maintain effective infection prevention programs. However, variation exists even among A-rated facilities, and patients facing high-risk procedures should dig deeper into infection-specific data when choosing where to receive care.

The tragedy of HAIs lies in their preventability. When hospitals implement proven prevention protocols with discipline and consistency, infection rates plummet. Patients selecting hospitals with sustained excellence in infection control—reflected in both overall safety grades and specific infection metrics—substantially reduce their risk of experiencing this preventable harm.

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Additional Sources for Sidebars

11. The Leapfrog Group. (2025). Hospital Safety Grade Methodology. https://www.hospitalsafetygrade.org/your-hospitals-safety-grade/methodology

12. Agency for Healthcare Research and Quality. (2024). Patient Safety Indicators Technical Specifications. https://qualityindicators.ahrq.gov/measures/psi_techs pec

13. Centers for Disease Control and Prevention. (2024). National Healthcare Safety Network (NHSN) Overview. https://www.cdc.gov/nhsn/index.html

14. Winters, B. D., Bharmal, A., Wilson, R. F., et al. (2016). Validity of the Agency for Health Care Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-Acquired Conditions. Medical Care, 54(12), 1105-1111. https://journals.lww.com/lww-medicalcare/Abstract/2016/12000/Validity_of_the_Agency_for_Health_Care_Research.9.aspx

15. Austin, J. M., Jha, A. K., Romano, P. S., Singer, S. J., Vogus, T. J., Wachter, R. M., & Pronovost, P. J. (2015). National hospital ratings systems share few common scores and may generate confusion instead of clarity. Health Affairs, 34(3), 423-430. https://www.healthaffairs.org/doi/10.1377/hlthaff.2014.0201

    Additional Sources on Healthcare-Associated Infections

16. Centers for Disease Control and Prevention. (2024). Healthcare-Associated Infections (HAI) Progress Report. https://www.cdc.gov/hai/data/portal/progress-report.html

17. Magill, S. S., Edwards, J. R., Bamberg, W., et al. (2014). Multistate Point-Prevalence Survey of Health Care-Associated Infections. New England Journal of Medicine, 370, 1198-1208. https://www.nejm.org/doi/full/10.1056/NEJMoa1306801

18. Umscheid, C. A., Mitchell, M. D., Doshi, J. A., Agarwal, R., Williams, K., & Brennan, P. J. (2011). Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs. Infection Control & Hospital Epidemiology, 32(2), 101-114. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/estimating-the-proportion-of-healthcareassociated-infections-that-are-reasonably-preventable-and-the-related-mortality-and-costs/8c0ABAA1633E24FD3E8C90934E8E1E5E

19. Zimlichman, E., Henderson, D., Tamir, O., et al. (2013). Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Internal Medicine, 173(22), 2039-2046. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1733452

20. Pronovost, P., Needham, D., Berenholtz, S., et al. (2006). An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. New England Journal of Medicine, 355, 2725-2732. https://www.nejm.org/doi/full/10.1056/NEJMoa061115

21. Yokoe, D. S., Anderson, D. J., Berenholtz, S. M., et al. (2014). A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates. Infection Control & Hospital Epidemiology, 35(S2), S21-S31. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/compendium-of-strategies-to-prevent-healthcareassociated-infections-in-acute-care-hospitals-2014-updates/4524FCC63127E4168B6AB20260C55136

22. Barlam, T. F., Cosgrove, S. E., Abbo, L. M., et al. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, 62(10), e51-e77. https://academic.oup.com/cid/article/62/10/e51/2462716

23. Anderson, D. J., Podgorny, K., Berríos-Torres, S. I., et al. (2014). Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35(S2), S66-S88. https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/strategies-to-prevent-surgical-site-infections-in-acute-care-hospitals-2014-update/9AFA23E32870F5D6FB9F5AF87A0F0379

24. California Department of Public Health. (2024). Healthcare-Associated Infections (HAIs) in California Hospitals. https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/HAI-Home.aspx

25. The Joint Commission. (2024). Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/preventing-central-line-associated-bloodstream-infections-a-global-challenge-a-global-perspective/