By MICHAEL MILLENSON
It was a small anecdote, buried in a prolonged profile in The New Yorker of Commerce Secretary Howard Lutnick, “Donald Trump’s Tariff Dealmaker-in-Chief.” However as a affected person security activist, the stark depiction of the impact of medical error felt like a sudden shock.
Lutnick, the article related, knew tragedy early in life: “his mom died of lymphoma whereas he was in highschool; in his first week of [Haverford] faculty, his father was by chance administered a deadly dose of chemotherapy. Different family receded into the background, leaving Lutnick and his two siblings on their very own.”
A medical error and, out of the blue, three youngsters are abruptly orphaned and successfully deserted. With World Affected person Security Day simply previous us on Sept. 17, I wished to place that devastating occasion into the broader affected person security context.
As is incessantly the case, The New York Occasions obituary of Sept. 15, 1979, for Solomon Lutnick gave no reason behind demise. There have been a handful of private {and professional} particulars (he was a historical past professor at Queens School) and that he died at age 51 at Syosset (Lengthy Island) Hospital.
Invisible Hurt
Sadly, treatment-caused hurt has typically been invisible, even the place it occurred. The 12 months earlier than Solomon Lutnick died, the primary research to look at hostile occasions at a number of hospitals concluded that given the advantages of contemporary medication, the incidence was “remarkably low.” The 1978 study, commissioned by California hospital and medical associations nervous about rising malpractice premiums, was overseen by physician-attorney Don Harper Mills, who assured the nervous sponsors there have been few “doubtlessly compensable occasions.”
There’s no indication Solomon Lutnick’s demise prompted a lawsuit; he was being handled for metastatic colon most cancers when a nurse by chance administered 100 instances the advisable chemotherapy dose, in keeping with accounts Howard Lutnick has shared elsewhere. It’s unclear how Syosset Hospital reacted, however the Mills research, reflecting the perspective of many on the time, didn’t rely deaths of people who the analysis crew assessed would have died anyway inside a 12 months.
Even with that methodology, when in my 1997 book I extrapolated Mills’ outcomes nationally, his “remarkably low” incidence of hurt amounted to 120,000 folks killed annually by medical care. I wonder if anybody informed the three Lutnick youngsters, “Your dad was going to die quickly, anyway,” and whether or not they discovered that any kind of consolation.
In 2025, addressing affected person hurt was way back presupposed to have change into a part of hospital tradition, however invisibility nonetheless continues. The Workplace of the Inspector Basic of the Division of Well being and Human Companies Hospitals has repeatedly discovered that tens of millions of Medicare sufferers yearly are harmed by their medical care. But hospitals nonetheless fail to seize even half of hurt occasions, whereas additionally failing to report two-thirds of occasions for which reporting is required, according to the most recent OIG report. Worse, few incidents of hurt are even investigated “and even fewer led to hospitals making enhancements for affected person security,” the OIG concluded.
Echoing One other Error
But it surely wasn’t solely the best way Solomon Lutnick’s avoidable demise would have been minimized throughout that period that struck me. It additionally stood out for its eerie echo of a later demise that grew to become a patient safety milestone. On Dec. 3, 1994, an obituary within the Boston Globe for its private well being columnist, Betsy Lehman, associated that the 39-year-old married mom of two younger daughters had died at Dana-Farber Most cancers Institute as a result of issues of breast most cancers. Nevertheless, it wasn’t till after a routine file overview by Dana-Farber clerks discovered the error, which was relayed to her household after which to her Globe colleagues, {that a} web page one story appeared on March 23, 1995, detailing how an unintended overdose of a strong chemotherapy drug had truly prompted Lehman’s demise.
Not like the error that killed Solomon Lutnick, this one concerned a Harvard-affiliated most cancers hospital and a distinguished native journalist whose husband even labored on the establishment the place she’d died — and had tried in useless to alert clinicians that one thing was very mistaken. As well as, a couple of months earlier than the Globe article appeared, two commentaries in JAMA criticized medical doctors for ignoring proof of “substantial” hurt. (A central ingredient of that proof was a research by Harvard researchers — once more, in response to rising malpractice charges — that examined New York State hospital data.)
This mix of components resulted in Betsy Lehman’s demise sparking a nationwide cascade of no-one-is-immune information protection of medical errors. The general public notion of treatment-caused hurt started to shift from a regrettable aspect impact of “fashionable medication” to a systemic hazard that might, and will, be addressed.
Cash Talks
Historical past was the main target of Solomon Lutnick’s profession. Cash was the main target for Howard Lutnick, who joined monetary companies agency Cantor Fitzgerald instantly after faculty and rose quickly in its ranks to change into chief govt officer. The historical past of the affected person security motion teaches the identical lesson, 12 months after 12 months: the simplest lever for altering conduct is cash.
So, for the occasion, the To Err is Human report by the distinguished Institute of Drugs in late 1999 shocked the nation by declaring that as much as 98,000 Individuals have been killed in hospitals annually by preventable medical error. The report triggered a public uproar, a White Home summons to well being care leaders, Congressional hearings and lots of guarantees. But a decade later, analysis confirmed nearly no substantive nationwide progress, a lot much less the slicing affected person hurt in half that was a five-year purpose of the IOM (now referred to as the Nationwide Academy of Drugs).
In distinction, take into account what occurred when the Facilities for Medicare & Medicaid Companies dedicated $1 billion to a multiyear effort that concerned paying teams like state hospital associations to assist networks of particular person hospitals attain particular objectives for affected person hurt discount. According to a CMS analysis, the Partnership for Sufferers slashed what are termed “hospital-acquired situations” by 17% between 2010 and 2013, stopping an estimated 50,000 deaths from 1.3 million hostile occasions and averting about $12 billion in well being care prices. Although consultants quibble concerning the methodology, there’s no query that financial incentives vastly outperformed eloquent skilled exhortations about “first, do no hurt.”
Make that “substantive” incentives. Since 2008, the federal authorities has required hospitals to report sure hospital-acquired situations, equivalent to leaving in a “overseas object” after surgical procedure, and mentioned Medicare gained’t pay for additional care necessitated by the sort of lapse. Though the HAC record has grown, its influence on affected person hurt has been puny.
“Non-payment for preventable hurt is proscribed and hospitals nonetheless receives a commission for almost all of the hospital admission,” famous Dr. Tejal Gandhi, chief security and transformation officer at Press Ganey and a veteran of a quarter-century in affected person security, after I reached out for her perspective. “The quantity of {dollars} in danger is negligible.”
Driving Actual Change
Let me change gears right here. As somebody who grew up in a Jewish household with a robust New York connection — my maternal grandfather, like Lutnick’s paternal grandfather, owned a laundry and dry cleansing enterprise in Manhattan — I ended up feeling a private connection to Lutnick. And I’ve had a small, personal experience with a family member’s medical error, as nicely. On that that flimsy foundation, enable me to supply some recommendation on how, in reminiscence of his father, Lutnick may assist forestall others from struggling an analogous devastating loss.
(A fast word: The household suffered additional devastation within the terror assaults of 9/11, when Cantor Fitzgerald workplaces at 2 World Commerce Heart suffered a direct hit. All three siblings labored for the corporate. Brother Gary died. Howard and Edie, who simply occurred to produce other commitments that morning, weren’t within the constructing.)
When you’re commerce secretary, not secretary of Well being and Human Companies, you’re not shy about talking up. And also you even have the president’s ear. HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz are sturdy proponents of consumerism, however consumerism doesn’t work with out dependable info. The very best hospital-specific affected person security info as we speak comes from the rankings of the Leapfrog Group. Whereas they’re not good, they’ve nonetheless constantly used reputational danger to drive change. (By the best way, Syosset Hospital now has an “A” Leapfrog grade.) Authorities must encourage this type of effort.
Extra broadly, the federal government ought to assist tear away medical error’s invisibility by telling suppliers to allow customers (in any other case often called sufferers) to report hostile occasions and have these experiences change into a part of official documentation, as advocated by Patients for Patient Safety. The OIG investigation of hospital non-reporting merely reinforces what activists have recognized for years concerning the trade’s “see no evil, hear no evil, report no evil” tendency.
Lastly, ratchet up monetary incentives to be actually efficient. Consider it as well being care tariffs that can encourage suppliers to revisit the best way they presently calculate the return on funding of, say, shopping for know-how designed to alert nurses if a post-surgical affected person is now not respiratory or endeavor an infection prevention for teenagers hospitalized with blood most cancers. These are actual examples, and I might go on. Ethical repugnance clearly hasn’t labored; let’s give dropping or being profitable an opportunity to weigh in.
Sure, the assorted well being care organizations, particular person activists and tutorial researchers devoted to lowering medical error all contribute to creating care safer. Nonetheless, I like to specific essentially the most fundamental precept of change this fashion: “Seize them by their wallets, and their hearts and minds will observe.”
Michael L. Millenson is president of Well being High quality Advisors & a daily THCB Contributor. This primary appeared in his Forbes column
