Patients may expect cleaner than clean conditions in a hospital – sterile even. Think again. In one of four hospitals across the country hand washing – the best-known way to prevent hospital infections – is apparently not a priority. Nearly a quarter of the hospitals – 23 percent – have yet to implement safe practices such as those.

That's according to a survey by hospital watchdog The Leapfrog Group. Overall, the results paint a picture of hospitals across the country struggling to provide safe care.

Health management company Castlight Health analyzed the results of the annual survey that measures a broad array of safety issues. It found that while hospitals overall showed improvement in 2014 for hand hygiene, rural hospitals aren’t performing as well as their urban counterparts.

"Rural or urban, affluent or safety net, there’s no excuse for a hospital to fail on hand hygiene," said Leah Binder, president and CEO of The Leapfrog Group, in announcing the findings of the survey. "It puts patients, clinicians, and all health care workers at risk when hand washing is not a priority. Hospital-acquired infections kill about 10 percent of those afflicted, according to the Healthcare-Associated Infections Progress Report by the Centers for Disease Control and Prevention."

[See also: Leapfrog: See list of safest hospitals in the US.] and [Leapfrog: See list of hospitals that got failing grades for safety.]

"While we trust our doctors and nurses to make us well, many hospital-acquired infections are caused by the contaminated hands of healthcare workers," Jennifer Schneider, MD, chief medical officer for Castlight Health, said in a statement. "Hospitals must not only put the right policies in place – they must also enforce them. This is perhaps one of the easiest steps a hospital can take toward patient safety, but it’s also one of the most important."

Other key findings from the report:

• The percentage of hospitals meeting all 10 of Leapfrog’s hand-hygiene practices increased from 69 percent in 2013 to 77 percent in 2014.
• Urban hospitals continue to outperform rural hospitals; about 20 percent more urban hospitals met Leapfrog’s standard and showed greater year-over-year improvement in meeting the standard.
• There is significant geographic variation in adoption of hand-hygiene safe practices: In five states, more than 90 percent of reporting hospitals met all practices, while in six states, only 60 percent or less of reporting hospitals met all practices.

Leapfrog also found that the rates of certain hospital-acquired conditions remain a problem. The rates varied "tremendously" among hospitals that reported on hospital-acquired injuries, infections, and pressure ulcers, the organization reports. One in six Leapfrog reporting hospitals have higher infection rates than expected for central line infections, and one in 10 perform poorly in preventing catheter-associated urinary tract infections.

On what appears to be a welcome improvement, a record number of hospitals are adopting computerized provider order entry to reduce potential medication prescribing errors, In 2014, a record 1,339 hospitals reported using a CPOE system in at least one inpatient unit, compared with only 384 hospitals in 2010.

However, these systems often fail, jeopardizing patients’ safety, Leapfrog points out.

"Medication errors are the most common mistakes made in hospitals, with one occurring on average every day per inpatient stay," according to Leapfrog. Studies such as one led by David Bates, MD, at Boston’s Brigham and Women’s Hospital, suggest that a well-designed CPOE system could substantially reduce these errors, Leapfrog officials point out.

Another area of concern is maternity care.

"While hospitals overall are making substantial progress, there’s still significant room for improvement to meet maternity care standards," according to Leapfrog. "In fact, less than one-third of hospitals meet Leapfrog’s standard for high-risk deliveries of very-low birthweight babies, and rates of episiotomies are far too high at 35 percent of birthing hospitals."

[See also: Hospitals must do better by nurses, says Leapfrog.]

A bright spot: Hospitals are decreasing deaths in the ICU through appropriate physician staffing.  More hospitals with intensive care units are complying with Leapfrog’s ICU Physician Staffing standard to decrease mortality. Studies show that meeting the Leapfrog standard for physician staffing can reduce mortality in the ICU by as much as 40 percent

The report released today is the fifth in a series of six reports examining key quality and safety measures at hospitals nationwide, based on data taken from the 2014 Leapfrog Hospital Survey of 1,501 U.S. hospitals and analyzed by Castlight Health. The initial reports on maternity care, high-risk procedures, computerized physician order entry, or CPOE, and nursing, as well as future publications in the report series, are available here.

Individual hospital results can be found here.

More information on Hospital Safety Score here.