Fear — and federal medical-information privacy rules — also make it hard for news media to tell individual patient safety stories. Facilities won't answer questions about cases, which reporters may not know about anyway unless a patient or family member calls. Then the information's hard to verify. Care providers who keep information from the state aren't volunteering it to the media.

While Utah has opted for a nonpunitive approach, it reserved one stick to go with its carrot. Sort of.

If the state disagrees with the root cause analysis that each facility must conduct after a sentinel event, it can write a dissent that goes to the facility. It can also express its dissatisfaction to health facility licensing. The drawback? State health officials must be invited to participate in the root cause analysis to begin with.

If the facility violates certain rules, it could lose certification or its license. Losing certification would end being paid to treat Medicare and Medicaid patients, says Douglas Springmeyer, Utah assistant attorney general.

Making care safer has been an evolutionary process. Several years ago, Utah broadened the search for patient-harm events by tying in hospital discharge codes and death certificate data. And it began to require hospitals to send it the same forms they send Medicare to be paid. By looking for certain care codes, they "found all sorts of patient safety red flags," James says.

They teamed those codes with LDS Hospital's "clinical triggers" system, and the level of detection surged again. With triggers, the electronic medical records system is programmed to look for signs care is not going as planned and notify care providers.

Nationwide, the fine-tuning and experimentation in the quest for safer health care has been ongoing. Not long ago, LDS Hospital joined the Mayo Clinic to test Mayo's list of 55 "events" chart reviewers should look for. Two independent doctors examined those they found.

"We found 26 percent of cases had some sort of care-associated events. Most we don't know how to prevent. They're not bad care, just the consequence of high-powered treatment," James says.

For example, doctors prescribing narcotic pain relievers after surgery know that a small subset of patients will have severe nausea and vomiting, but they don't know which patients. And they'll need anti-nausea drugs to control that, which means additional medical monitoring or intervention in response to an earlier treatment — a patient safety "event."

Nationwide, more hospitals are adopting clinical triggers, improved chart reviews and other tools to find unintended consequences of treatment. The evidence collected by Mayo and LDS Hospital's collaboration has been folded into a national 5 Million Lives campaign.