{"id":8483,"date":"2025-09-25T21:21:47","date_gmt":"2025-09-25T21:21:47","guid":{"rendered":"https:\/\/medical-article.com\/?p=8483"},"modified":"2025-09-25T21:21:47","modified_gmt":"2025-09-25T21:21:47","slug":"lessons-from-the-medical-error-that-orphaned-a-cabinet-secretary","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=8483","title":{"rendered":"Lessons From The Medical Error That Orphaned A Cabinet Secretary"},"content":{"rendered":"
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By MICHAEL MILLENSON<\/p>\n

It was a small anecdote, buried in a lengthy profile in\u00a0The New Yorker<\/em>\u00a0of Commerce Secretary Howard Lutnick, \u201cDonald Trump\u2019s Tariff Dealmaker-in-Chief.\u201d But as a patient safety activist, the stark depiction of the effect of medical error felt like a sudden shock.<\/p>\n

Lutnick,\u00a0the article related<\/a>, knew tragedy early in life: \u201chis mother died of lymphoma while he was in high school; in his first week of [Haverford] college, his father was accidentally administered a fatal dose of chemotherapy.\u00a0<\/em>Other relatives receded into the background, leaving Lutnick and his two siblings on their own.\u201d<\/p>\n

A medical error and, suddenly, three kids are abruptly orphaned and effectively abandoned. With World Patient Safety Day just past us on Sept. 17, I wanted to put that devastating event into the broader patient safety context.<\/p>\n

As is frequently the case,\u00a0The<\/em>\u00a0New York Times<\/em>\u00a0obituary of Sept. 15, 1979, for Solomon Lutnick gave no cause of death. There were a handful of personal and professional details (he was a history professor at Queens College) and that he died at age 51 at Syosset (Long Island) Hospital.<\/p>\n

Invisible Harm<\/h2>\n

Unfortunately, treatment-caused harm has often been invisible, even where it occurred. The year before Solomon Lutnick died, the first study to examine adverse events at multiple hospitals concluded that given the benefits of modern medicine, the incidence was \u201cremarkably low.\u201d\u00a0The 1978 study<\/a>, commissioned by California hospital and medical associations worried about rising malpractice premiums, was overseen by physician-attorney Don Harper Mills, who assured the worried sponsors there were few \u201cpotentially compensable events.\u201d<\/p>\n

There\u2019s no indication Solomon Lutnick\u2019s death prompted a lawsuit; he was being treated for metastatic colon cancer when a nurse accidentally administered 100 times the recommended chemotherapy dose, according to accounts Howard Lutnick has shared elsewhere. It\u2019s unclear how Syosset Hospital reacted, but the Mills study, reflecting the attitude of many at the time, didn\u2019t count deaths of individuals who the research team assessed would have died anyway within a year.<\/p>\n

Even with that methodology, when\u00a0in my 1997 book I extrapolated<\/a>\u00a0Mills\u2019 results nationally, his \u201cremarkably low\u201d incidence of harm amounted to 120,000 people killed each year by medical care. I wonder whether anyone told the three Lutnick children, \u201cYour dad was going to die soon, anyway,\u201d and whether they found that any sort of comfort.<\/p>\n

In 2025, addressing patient harm was long ago supposed to have become part of hospital culture, but invisibility nonetheless continues. The Office of the Inspector General of the Department of Health and Human Services Hospitals has repeatedly found that millions of Medicare patients every year are harmed by their medical care. Yet hospitals still fail to capture even half of harm events, while also failing to report two-thirds of events for which reporting is required,\u00a0according to the most recent OIG report<\/a>.\u00a0Worse, few incidents of harm are even investigated \u201cand even fewer led to hospitals making improvements for patient safety,\u201d the OIG concluded.<\/p>\n

Echoing Another Error<\/h2>\n

But it wasn\u2019t only the way Solomon Lutnick\u2019s avoidable death would have been minimized during that era that struck me. It also stood out for its eerie echo of a later death that became a\u00a0patient safety milestone<\/a>. On Dec. 3, 1994, an obituary in the\u00a0Boston Globe<\/em>\u00a0for its personal health columnist, Betsy Lehman, related that the 39-year-old married mother of two young daughters had died at Dana-Farber Cancer Institute due to complications of breast cancer. However, it wasn\u2019t until after a routine record review by Dana-Farber clerks found the error, which was relayed to her family and then to her\u00a0Globe<\/em>\u00a0colleagues, that a page one story appeared on March 23, 1995, detailing how an accidental overdose of a powerful chemotherapy drug had actually caused Lehman\u2019s death.<\/p>\n

<\/span><\/p>\n

Unlike the mistake that killed Solomon Lutnick, this one involved a Harvard-affiliated cancer hospital and a prominent local journalist whose husband even worked at the institution where she\u2019d died \u2014 and had tried in vain to alert clinicians that something was very wrong. In addition, a few months before the\u00a0Globe<\/em>\u00a0article appeared, two commentaries in\u00a0JAMA<\/em>\u00a0criticized doctors for ignoring evidence of \u201csubstantial\u201d harm. (A central element of that evidence was a study by Harvard researchers \u2014 again, in response to rising malpractice rates \u2014 that examined New York State hospital records.)<\/p>\n

This combination of elements resulted in Betsy Lehman\u2019s death sparking a national cascade of no-one-is-immune news coverage of medical errors. The public perception of treatment-caused harm began to shift from a regrettable side effect of \u201cmodern medicine\u201d to a systemic danger that could, and should, be addressed.<\/p>\n

Money Talks<\/h2>\n

History was the focus of Solomon Lutnick\u2019s career. Money was the focus for Howard Lutnick, who joined financial services firm Cantor Fitzgerald immediately after college and rose rapidly in its ranks to become chief executive officer. The history of the patient safety movement teaches the same lesson, year after year: the most effective lever for changing behavior is money.<\/p>\n

So, for the instance, the\u00a0To Err is Human<\/em><\/a>\u00a0report by the prestigious Institute of Medicine in late 1999 shocked the nation by declaring that up to 98,000 Americans were killed in hospitals each year by preventable medical error. The report triggered a public uproar, a White House summons to health care leaders, Congressional hearings and many promises. Yet a decade later, research showed virtually no substantive national progress, much less the cutting patient harm in half that was a five-year goal of the IOM (now called the National Academy of Medicine).<\/p>\n

In contrast, consider what happened when the Centers for Medicare & Medicaid Services committed $1 billion to a multiyear effort that involved paying groups like state hospital associations to help networks of individual hospitals reach specific goals for patient harm reduction.\u00a0According to a CMS analysis<\/a>, the Partnership for Patients slashed what are termed \u201chospital-acquired conditions\u201d by 17% between 2010 and 2013, preventing an estimated 50,000 deaths from 1.3 million adverse events and averting about $12 billion in health care costs. Though experts quibble about the methodology, there\u2019s no question that monetary incentives vastly outperformed eloquent professional exhortations about \u201cfirst, do no harm.\u201d<\/p>\n

Make that \u201csubstantive\u201d incentives. Since 2008, the federal government has required hospitals to report certain hospital-acquired conditions, such as leaving in a \u201cforeign object\u201d after surgery, and said Medicare won\u2019t pay for extra care necessitated by this type of lapse. Although the HAC list has grown, its impact on patient harm has been puny.<\/p>\n

\u201cNon-payment for preventable harm is limited and hospitals still get paid for the majority of the hospital admission,\u201d noted Dr. Tejal Gandhi, chief safety and transformation officer at Press Ganey and a veteran of a quarter-century in patient safety, when I reached out for her perspective. \u201cThe amount of dollars at risk is negligible.\u201d<\/p>\n

Driving Real Change<\/h2>\n

Let me switch gears here. As someone who grew up in a Jewish family with a strong New York connection \u2014 my maternal grandfather, like Lutnick\u2019s paternal grandfather, owned a laundry and dry cleaning business in Manhattan \u2014 I ended up feeling a personal connection to Lutnick. And I\u2019ve had a\u00a0small, personal experience with a family member\u2019s medical error<\/a>, as well. On that that flimsy basis, allow me to offer some advice on how, in memory of his father, Lutnick might help prevent others from suffering a similar devastating loss.<\/p>\n

(A quick note: The family suffered further devastation in the terror attacks of 9\/11, when Cantor Fitzgerald offices at 2 World Trade Center suffered a direct hit. All three siblings worked for the company. Brother Gary died. Howard and Edie, who just happened to have other commitments that morning, were not in the building.)<\/p>\n

While you\u2019re commerce secretary, not secretary of Health and Human Services, you\u2019re not shy about speaking up. And you also have the president\u2019s ear. HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz are strong proponents of consumerism, but consumerism doesn\u2019t work without reliable information. The best hospital-specific patient safety information today comes from the ratings of the Leapfrog Group. While they\u2019re not perfect, they have nonetheless consistently used reputational risk to drive change. (By the way, Syosset Hospital\u00a0now has an \u201cA\u201d Leapfrog grade<\/a>.) Government needs to encourage this kind of effort.<\/p>\n

More broadly, the government should help tear away medical error\u2019s invisibility by telling providers to permit consumers (otherwise known as patients) to report adverse events and have those reports become part of official documentation, as advocated by\u00a0Patients for Patient Safety<\/a>. The OIG investigation of hospital non-reporting simply reinforces what activists have known for years about the industry\u2019s \u201csee no evil, hear no evil, report no evil\u201d tendency.<\/p>\n

Finally, ratchet up financial incentives to be really effective. Think of it as health care tariffs that will encourage providers to revisit the way they currently calculate the return on investment of, say, buying technology designed to alert nurses if a post-surgical patient is no longer breathing or undertaking infection prevention for kids hospitalized with blood cancer. These are\u00a0actual examples<\/a>, and I could go on. Moral repugnance obviously hasn\u2019t worked; let\u2019s give losing or making money a chance to weigh in.<\/p>\n

Yes, the various health care organizations, individual activists and academic researchers dedicated to reducing medical error all contribute to making care safer. Still, I like to express the most basic principle of change this way: \u201cGrab them by their wallets, and their hearts and minds will follow.\u201d<\/p>\n

Michael L. Millenson is president of Health Quality Advisors & a regular THCB Contributor. This first appeared in his Forbes column<\/a><\/em><\/p>","protected":false},"excerpt":{"rendered":"

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