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One of the three pillars of the Institute for Healthcare Improvement’s Triple Aim initiative is to improve the quality of healthcare individuals receive. This includes providing safe, effective care. However, several reports from the Institute of Medicine and other national organizations conclude that the quality and safety of care provided in the United States remains suboptimal.

Now The Leapfrog Group, which gives hospitals a letter grade based on their safety record, has published research showing that 206,021 avoidable deaths occur in U.S. hospitals each year. The study also found that 33,459 lives could be saved if every hospital performed as well as “A”-rated facilities. Even “A” hospitals, however, accounted for nearly 44,000 avoidable deaths.

The analysis found that the average number of deaths ranged from 5.13 per 1,000 admissions in “A” hospitals to 7.68 per 1,000 admissions in “D” and “F” hospitals. Overall, compared with “A” hospitals, the average risk of death was 8.5% higher in “B” hospitals, 35.2% higher in “C” hospitals, and 49.8% higher in “D” and “F” hospitals.

Of the 2,571 hospitals Leapfrog evaluates twice annually, just 31% earned an “A” in its most recent rankings, while just 6% have received an “A” for 3 consecutive years. Vermont has the highest number of “A” hospitals, with 83% achieving that ranking. No hospitals in the District of Columbia, Arkansas, and Wyoming received an “A” grade.

The Leapfrog study also found that the greatest risk of in-hospital death came from hospital-onset methicillin-resistant Staphylococcus aureus (MRSA), which accounted for 22.6% of deaths, and hospital-onset Clostridium difficile, which accounted for 23% of deaths. These conditions will be added to Medicare’s Hospital-Acquired Condition Reduction Program, which penalizes hospitals for excessive hospital-acquired conditions (HACs), in 2017.

While the rate of HACs in U.S. hospitals has been declining since 2010, an October 2015 report from the Agency for Healthcare Research and Quality found that more than 10% of hospitalized patients died in 2013 as a result of HACs, a figure that does not include deaths associated with C. difficile and MRSA.

“It is time for every hospital in America to put patient safety at the top of their priority list, because tens of thousands of lives are stake,” said Leah Binder, president and CEO of The Leapfrog Group, in a press release. “The Hospital Safety Score alerts consumers to the dangers, but as this analysis shows, even ‘A’ hospitals are not perfectly safe.”