Lessons of Medical Mistakes from Orphan Secretary – Healthcare Blog

Michael Millenson

This is a small anecdote, buried in a long outline New Yorker Commerce Secretary Howard Lutnick, “Donald Trump’s tariff trader president.” But, as a patient safety activist, a sharp portrayal of the effects of medical errors feels like a sudden shock.

Lutnik, This article is relatedI knew the tragedy early in my life: “His mother died of lymphoma in high school; [Haverford] In college, his father accidentally took fatal chemotherapy. The other relatives retreated to the background, leaving Lutnik and his two siblings behind. ”

Medical error, suddenly, the three children were suddenly in the orphanage and effectively gave up. As World Patient Safety Day passes us on September 17, I want to place this devastating event in a wider range of patient safety environments.

often this New York Times The prosecutor on September 15, 1979, because Solomon Lutnick had no cause of death. There are a few personal and professional details (he is a history professor at Queen's College), who died at the age of 51 at Syosset (Long Island) Hospital.

Invisible harm

Unfortunately, even if this happens, it is not visible. The first study examining adverse events in multiple hospitals a year before Solomon Lutnick's death concluded that the incidence rate was “very low”, given the benefits of modern medicine. Research in 1978Commissioned by the California Hospitals and Medical Association for concerns about the increase in malpractice premiums, it was supervised by doctors-Don Harper Mills, who assured worried sponsors that there were few “potential compensation events”.

There is no sign that the death of Solomon Lutnick has sparked a lawsuit. According to Howard Lutnick, he is receiving treatment for metastatic colon cancer when the nurse unexpectedly gave 100 times the recommended chemotherapy dose. It is not clear how the Syosset Hospital's reaction was reacted, but the Mills Research reflects the attitudes of many people at the time and did not calculate the individual deaths evaluated by the research team, which would die within a year anyway.

Even with this method, In my 1997 book, I inferred Mills' national result, his “very low” injury rate is 120,000 people killed by medical treatment each year. I wonder if anyone told three Lutnik's children: “Your father is going to die as soon as possible anyway” and if they found any kind of comfort.

In 2025, addressing patient injuries long ago should have been part of hospital training, but it is still hidden. The Office of the Inspector General of the Hospital of Health and Public Services has repeatedly found that millions of Medicare patients are harmed by health services each year. However, hospitals still cannot capture half of the injuries, and there is no report of two-thirds of the incidents that need to be reported. According to recent OIG reports. Worse, OIG concluded that few injuries “have even led to hospitals making improvements to patients’ safety,” OIG concluded.

Echo another error

But it was not only Solomon Lutnick's avoidable way of death, in an era that shocked me. It also stands out for its creepy death Milestones for patient safety. December 3, 1994, Boston Global The 39-year-old married mother's two young daughters died at the Dana-Farber Cancer Institute due to complications from breast cancer. However, it was not until the routine record review of Dana-Farber clerk that the error was discovered and later transferred to her family Earth Colleagues, One Page Story, published on March 23, 1995, details how an unexpected overdose of a powerful chemotherapy drug actually led to Lehman's death.

Unlike the mistake that killed Solomon Lutnick, it involved a Harvard cancer hospital and a well-known local journalist whose husband even worked at the institution where she died and tried to vainly remind the clinician that it was very wrong. Also, a few months ago Earth The article appears, there are two comments Jama Criticizing doctors for ignoring evidence of “significant” harm. (A core element of the evidence is a study by Harvard researchers – again responding to the rise in malfeasance rates, examining records from New York State Hospitals.)

The combination of this element led to the death of Betsy Lehman, which triggered a series of unwelcome medical error news reports nationwide. The public perception of the harm caused by treatment has begun to shift from the regrettable side effects of “modern medicine” to the systemic dangers that may and should be addressed.

Money talk

History is the focus of Solomon Lutnick's career. Money is the focus of Howard Lutnick, who joined the financial services company Cantor Fitzgerald immediately after graduating from college and quickly became its position as CEO. History of patient safety exercise year after year: The most effective leverage to change behavior is money.

Therefore, for this example, The error is human The prestigious Institute of Medical Research shocked the United States in late 1999, announcing that up to 98,000 Americans were killed in hospitals each year. The report sparked public uproar, with the White House calling out to health care leaders, congressional hearings and many promises. However, ten years later, there was little substantial national progress in the study, not to mention that half of the patient harm was the five-year goal of IOM (now known as the National School of Medicine).

By contrast, consider the Medicare & Medicaid Service Center that awarded $1 billion to a multi-year effort involving paying paid groups such as the State Hospital Association to help individual hospital networks achieve specific goals of reducing patient injuries. Analysis according to CMSbetween 2010 and 2013, partnerships for patients cut so-called “hospital access status” by 17%, preventing 1.3 million adverse events from 50,000 deaths and avoiding about $12 billion in health care costs. Although experts have questions about this approach, there is no doubt that monetary incentives greatly demonstrate eloquent professional advice to “first, don’t hurt.”

Causes “substantive” incentives. Since 2008, the federal government has asked hospitals to report diseases acquired by certain hospitals, such as “foreign bodies” after surgery, and said Medicare will not pay for the additional care required for this type of failure. Although the HAC list has grown, its impact on patient harm is minimal.

“Payments for unpreventable injuries are limited and hospitals are still paid for admission to most hospitals,” Dr. Tejal Gandhi, Chief Safety and Transformation Officer at Press Ganey, a 25th Century veteran of patient safety. “The number of risky dollars is negligible.”

Drive real change

Let me switch gears here. As someone who grew up in a Jewish family with a close connection to New York in a Jewish family – my grandfather, like Lutnik’s, owns a laundry and dry cleaning business in Manhattan – I ended up having a personal connection with Lutnik. Moreover, I also have a very small personal experience because of medical errors from family members. Based on this, allow me to give some advice in memory of his father, Lutnick, who may help others suffer similar devastating losses.

(Quick Note: When the 9/11 terrorist attacks the family suffered further damage, the Cantor Fitzgerald offices at 2 World Trade Centers were hit directly. All three siblings worked in the company. Brother Gary passed away. Howard and Edie had just made other promises that morning, not in the building.)

When you are the Secretary of Commerce, not the Minister of Health and Human Services, you are not shy and speak out. And you have the president's ears, too. HHS Secretary Robert F. Today’s best hospital-specific patient safety information comes from the ratings of the Leapfrog group. Although they are not perfect, they always use reputational risks to drive change. (BTW, Syosset Hospital Now there is “A” to cross the level. ) The government needs to encourage such efforts.

From a broader perspective, governments should help eliminate the invisibility of medical errors by telling providers to allow consumers (otherwise referred to as patients) to report adverse events and make these reports part of official documents, e.g. Patient safe patients. OIG's investigation into non-reports has only strengthened the radicals' knowledge that “invisible evil, cannot hear evil, and does not report evil” over the years.

Finally, economic incentives are raised to be truly effective. It can be considered a levy for health care levy, which can encourage providers to revisit their current calculation of ROI, such as purchasing technology, which is designed to remind nurses if the patient no longer breathes or prevents infection in children who prevent blood cancer after surgery. These are all Actual examplesI can continue. Moral disgust obviously didn't work. Let us lose or make money an opportunity.

Yes, various health care organizations, individual activists and academic researchers are committed to reducing medical errors, which all helps make care safer. Still, I like to express the most basic principle of change in this way: “Catch their wallets and their hearts and minds will follow.”

Michael L. This first appeared in his Forbes column