By Michael Millenson
It was a small anecdote, buried in a legal profile in The New Yorker o Secretary of Commerce Howard Lutnick, “Donald Trump’s rates trafficker in chief.” But as a patient safety activist, the marked description of the effect of medical error was felt as a sudden shock.
Lutnick, The related articleHe knew the early tragedy in life: “His mother died or lymphoma while he was in high school; in his first week or [Haverford] College, his father accidentally received a fatal dose of chemotherapy. Other relatives backed down in the background, leaving Lutnick and their two brothers alone. “
A medical error and, suddenly, three children are abruptly orphaned and abandoned effectively. With World Patient Safety Day just beyond September 17, I wanted to put that devastating event in the wider patient safety context.
As is the case, He New York Times Obitarian of September 15, 1979 for Solomon Lutnick did not give cause of death. There was a handful of personal and professional details (he was a history professor in Queens College) and who died at 51 at the Syosset Hospital (Long Island).
Invisible damage
Unfortunately, treatment in treatment has often been invisible, even when it happened. The year before Solomon Lutnick died, the first study that examines the events of advertisements in multiple hospitals concluded that, given the benefits of modern medicine, the incidence was “remarkable fall.” The 1978 studyCommissioner for medical associations and California hospital concerned about the increase in negligence premiums, was supervised by the doctor and doctor Don Harper Mills, who assured the worried sponsors that there were “potentially compensable events.”
There are no indications that the death of Solomon Lutnick caused a lawsuit; It was being treated by metastatic colon cancer when a nurse accidentally administered 100 times the recommended chemotherapy dose, according to the accounts that Howard Lutnick has shared elsewhere. It is not clear how SosySet Hospital reacted, but Mills’s studies, which reflect the attitude of many at that time, did not tell the death of the people that the research team evaluated anyway within a year.
Even with that methodology, when In my 1997 book I extrapolated The results of Mills nationwide, its “remarkable decline” incidence of damage amounted to 120,000 people killed each year by medical care. I wonder if someone told the three children Lutnick: “Your father was going to die soon, anyway,” and if they found some kind of comfort.
In 2025, it was supposed to address the patient damage became part of hospital culture, but the invisibility continues. The Office of the Inspector General of the Department of Hospitals of the Department of Health and Human Services has repeatedly found that millions of patients with medicines are harmed by their medical care. However, hospitals cannot yet capture only half or damage events, while they do not inform two thirds of the events for which reports are required, In accordance with the OIG report more recently. Worse, few damage incidents are even investigated “and the same led hospitals to make improvements for patient safety,” the OIG concluded.
Making another mistake
But it was only the way in which the avoidable death of Solomon Lutnick would have minimized the duration of that time that surprised me. He also stood out for his honor echo or a subsequent death that became a Patient safety milestone. On December 3, 1994, an obitarian in the Boston Globe For his personal health columnist, Betsy Lehman, it was related that the 39-year-old mother of two daughters had died at the Dana-Farber cancer institute due to breast cancer complications. However, it was not after a routine registration review of Dana-Farber employees found the error, which was transmitted to re-family and then to it Globe Colleagues, which appeared a history of page one on March 23, 1995, which details how an accidental overdose of a powerful chemotherapy medication had captivated Lehman’s death.
Unlike the error that killed Solomon Lutnick, he involved a Harvard affiliated cancer hospital and an outstanding local journalist whose husband even worked in the institution where she also, a few months before Globe An article appeared, two comments in Jama He criticized doctors for ignoring the evidence of “substantial” damage. (A central element of that evidence was a study conducted by Harvard researchers, again, in response to the increase in negligence rates, which examined the records of the New York State Hospital).
This combination of elements resulted in the death of Betsy Lehman that caused a national medical news coverage of anyone-is-isne. The public perception of the consecutive damage of treatment began to change an unfortunate side effect of “modern medicine” to a systemic danger that could and should be addressed.
Money conversations
The story was the focus of Solomon Lutnick’s career. The money was the focus for Howard Lutnick, who joined the firm of financial services Cantor Fitzgerald immediately after university and rapidly rose in his ranks to become an executive director. The history of the patient safety movement teaches the same lesson, year after year: the most effective lever to change behavior is money.
Then, in the case, the Err is human The report of the prestigious Institute of Medicine at the end of 1999 surprised the Nation by stating that up to 98,000 Americans were killed in hospitals every year by preventable medical error. The report triggered a public urrar, a cup of the White House to medical care leaders, Congress audiences and many promises. However, a decade later, the investigation showed a virtual substantive national progress, much less the damage of the cutting patient in half that was a five -year objective of the OM (now called the National Academy of Medicine).
On the contrary, consider what happened when the Medicare and Medicaid service centers committed $ 1 billion to an effort of several years that involved paying groups such as state hospital associations to help the networks of individual hospitals to be achieved. In accordance with a CMS analysisThe Association for Patients cut what are called “Hospital acquired conditions” by 17% between 2010 and 2013, avoiding approximately 50,000 deaths for 1.3 million advertisers events and avoiding approximately $ 12 billion in medical care costs. Thought experts are discussed about the methodology, there is no doubt that monetary incentives set eloquent professional exhortations about “first, do not harm.”
Make those “nouns” incentives. Since 2008, the Federal Government has required hospitals to denounce certain conditions acquired in the hospital, such as going in a “foreign object” after surgery, and said that Medicare will not pay the additional attention necessary for this type of period. Althegh, the list has grown, its impact on patient damage has been insignificant.
“The lack of payment for preventable damage is limited and hospitals are still paid for the majority of hospital admission,” said Dr. Tabla Gandhi, director of security and transformation of Press Ganey and a veteran of a quarter of a century in patient safety, when I looked for their perspective. “The amount of dollars at risk is insignificant.”
Realize
Let me change your march here. Like some who grew up in a Jewish family with a strong connection in New York, my maternal grandfather, such as Lutnick’s paternal grandfather, was the owner of a laundry and a dry cleaning business in Manhattan, I ended up feeling a staff to a personal character. And I have had a Small and personal experience with the medical error of a family memberalso. On that that base weak, allow me to sacrifice some tips on how, in memory of his father, Lutnick could help prevent others from suffering a similar devastating loss.
(A quick note: the family suffered greater devastation in the terrorist attacks of September 11, when the offices of Cantor Fitzgerald in 2 World Trade Center suffered a direct success. The three brothers worked for the company. Brother Gary Dave and Edie, what were not in the building).
While its Secretary of Commerce, not secretary of Health and Human Services, is not shy to speak. And you also have the president’s ear. The secretary of the HHS, Robert F. Kennedy Jr. and the CMS administrator, Dr. Mehmet Oz, are strong pronements of consumerism, but consumerism does not work without reliable information. The best specific hospital patient security information comes from the LEAPFROG group grades. While they are not perfect, they have not used the constantly constant risk of reputation to boost change. (By the way, Syosset Hospital Now he has a jump rating “A”.) The government needs to encourage this child of effort.
In more general terms, the Government should help eliminate the invisibility of medical error by counts suppliers to allow consumers (also known as patients) to inform advertising events and make these reports become part of the official documentation, as defended by Patients for patient safety. The OIG investigation of the lack of hospital reports simply reinforces what activists have known for years about the “does not look bad, not listening badly, does not report evil trend.”
Finally, it increases financial incentives to be really effective. Think about it as medical care tariffs that will encourage suppliers to visit the way they currently calculate the return on investment of, for example, the purchase of technology designed to alert nurses if a post -surgical patient is no longer a hospitable for hospection children for children, these are. Real examplesAnd I could continue. Moral disgust has obviously not worked; We lose the opportunity to weigh.
Yes, the various medical care organizations, individual activists and academic researchers dedicated to reducing medical error contribute to making care more safely. Even so, I like to express the most basic principle of change in this way: “Atrápala for their wallets, and their hearts and minds will continue.”
Michael L. Millenson is president of health quality advisors and a regular THCB taxpayer. This first appeared in Your Forbes column
