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Central Harnett Hospital
Lillington, North Carolina 27546
Preventing and Responding to Patient Harm
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Steps to Avoid Harm |
Hospitals have all of the following processes and protocols in place: effective leadership to prevent patient harm, regular surveys of staff to ensure they feel safe to speak up if they see a mistake, effective nursing plans to prevent patient harm, and handwashing protocols to reduce healthcare associated infections. |
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Appropriate Use of Antibiotics |
Hospitals should have a program to combat antibiotic over-prescribing that includes all seven (7) core elements developed by the Centers for Disease Control and Prevention (CDC). |
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Responding to Never Events |
Hospitals should have a never events policy that includes all nine (9) actions that should occur following a “never event,” which includes apologizing to the patient and not charging for costs associated with the never event. |
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Medication Safety
Measure name | Leapfrog’s Standard | Hospital’s Progress | ||||||||||
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Safe Medication Ordering |
Hospitals should have doctors and other licensed prescribers enter at least 85% of inpatient medication orders through the CPOE system, and via a test, have demonstrated that prescribers are alerted to at least 60% of serious medication ordering errors. |
![]() ACHIEVED THE STANDARD |
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This Hospital's Percentage of Inpatient Medication Orders Entered Electronically: 85% or greater This Hospital’s CPOE Test Score: Full Demonstration of National Safety Standard for Decision Support |
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Medication Reconciliation |
Hospitals should use a nationally endorsed protocol to track how well they are collecting and maintaining inpatient medication lists. |
![]() ACHIEVED THE STANDARD |
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Safe Medication Administration |
Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA system includes decision support to prevent errors and the hospital has processes to prevent workarounds. |
![]() ACHIEVED THE STANDARD |
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Healthcare Associated Infections
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Infection in the Blood |
Hospitals should have fewer than expected central-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
![]() DECLINED TO RESPOND |
This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services at https://www.medicare.gov/hospitalcompare/search.html. |
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Infection in the Urinary Tract |
Hospitals should have fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
![]() DECLINED TO RESPOND |
This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services at https://www.medicare.gov/hospitalcompare/search.html. |
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C. difficile Infection |
Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
![]() DECLINED TO RESPOND |
This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services at https://www.medicare.gov/hospitalcompare/search.html. |
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MRSA Infection |
Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
![]() DECLINED TO RESPOND |
This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services at https://www.medicare.gov/hospitalcompare/search.html. |
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Surgical Site Infection After Colon Surgery |
Hospitals should have fewer than expected surgical site infections after major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC’s National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more infections than expected. |
![]() DECLINED TO RESPOND |
This hospital was asked to report its infection data directly to The Leapfrog Group and chose not to. However, some information about this hospital’s infection record may be available through the Centers for Medicare and Medicaid Services at https://www.medicare.gov/hospitalcompare/search.html. |
Maternity Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Cesarean Sections |
This is defined as first-time mothers giving birth to a single baby, at full-term, in the head-down position delivering their babies through a C-section. Hospitals should have a C-section rate of 23.9% or less. |
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Early Elective Deliveries |
This is defined as mothers scheduling cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should have an early elective delivery rate of 5% or less. |
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Episiotomies |
This is defined as mothers having an incision made in the perineum (the birth canal) during childbirth. Hospitals should have an episiotomy rate of is 5% or less. |
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Maternity Care Processes |
Hospitals should screen at least 90% of babies for jaundice and at least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. |
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High-Risk Deliveries |
To achieve Leapfrog's standard, hospitals must deliver at least 50 very-low birth weight babies per year and ensure that at least 90% of mothers receive antenatal steroids prior to delivery OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies and ensure that at least 90% of mothers receive antenatal steroids prior to delivery. |
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Pediatric Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Experience of Children and their Parents |
Hospitals should perform better than most hospitals in five (5) areas:
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Radiation Dose for Abdomen/Pelvis Scans |
Hospitals should ensure their average CT radiation dose for routine CT scans of the abdomen and pelvis falls within national benchmarks. |
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Radiation Dose for Head Scans |
Hospitals should ensure that their average radiation dose for routine CT scans of the head falls within national benchmarks. |
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Critical Care
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Specially Trained Doctors Care for Critical Care Patients |
The hospital has intensivists present on-site at least eight hours a day, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately reach the patient. |
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Complex Adult Surgery
Measure name | Leapfrog’s Standard | Hospital’s Progress |
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Carotid Artery Surgery |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
![]() DECLINED TO RESPOND |
Mitral Valve Repair and Replacement |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
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Open Aortic Procedures |
Hospitals should perform at least 10 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
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Bariatric Surgery for Weight Loss |
Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. |
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Esophageal Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 7 procedures annually. |
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Lung Resection for Cancer |
Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. |
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Pancreatic Resection for Cancer |
Hospitals should perform at least 20 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. |
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Rectal Cancer Surgery |
Hospitals should perform at least 16 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 6 procedures annually. |
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Central Harnett Hospital
215 Brightwater Dr
Lillington, North Carolina 27546
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