It was a small anecdote, buried in a lengthy profile in The New Yorker of Commerce S Howard Lutnick, “Donald Trump’s Tariff Dealmaker-in-Chief.” But as a patient safety activist, the stark depiction of the effect of medical error felt like a sudden shock.
Lutnick, the article related, knew tragedy early in life: “his 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. Other relatives receded into the background, leaving Lutnick and his two siblings on their own.”
A medical error and, suddenly, three kids are abruptly orphaned and effectively abandoned. With World Patient Safety Day approaching on Sept. 17, I wanted to put that devastating event into the broader patient safety context.
As is frequently the case, the New York Times obituary 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.
Invisible Harm
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 “remarkably low.” The 1978 study, 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 “potentially compensable events.”
There’s no indication Solomon Lutnick’s 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’s unclear how Syosset Hospital reacted, but the Mills study, reflecting the attitude of many at the time, didn’t count deaths of individuals who the research team assessed would have died anyway within a year.
Even with that methodology, when in my 1997 book I extrapolated Mills’ results nationally, his “remarkably low” incidence of harm amounted to 120,000 people killed each year by medical care. I wonder whether anyone told the three Lutnick children, “Your dad was going to die soon, anyway,” and whether they found that any sort of comfort.
In 2025, when addressing patient harm was long ago supposed to have become part of hospital culture, 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 don’t capture even half of harm events, while also failing to report two-thirds of events for which reporting is required, according to the most recent OIG report. Worse, few incidents of harm are even investigated “and even fewer led to hospitals making improvements for patient safety,” the OIG concluded.
Echoing Another Error
But it wasn’t only the way Solomon Lutnick’s 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 patient safety milestone. On Dec. 3, 1994, an obituary in the Boston Globe for 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’t until after a routine record review by Dana-Farber clerks found the error, which was relayed to her family and then to her Globe colleagues, that a page one story appeared on March 23, 1995 detailing how an accidental overdose of a powerful chemotherapy drug had actually caused Lehman’s death.
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’d died – and had tried in vain to alert clinicians that something was very wrong. In addition, a few months before the Globe article appeared, two commentaries in JAMA criticized doctors for ignoring evidence of “substantial” harm. (A central element of that evidence was a study by Harvard researchers – again, in response to rising malpractice rates – that examined New York State hospital records.)
The combination of those elements resulted in Betsy Lehman’s 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 “modern medicine” to a systemic danger that could, and should, be addressed.
Money Talks
History was the focus of Solomon Lutnick’s 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.
So, for the instance, the To Err is Human report 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).
In contrast, consider what happened when the Centers for Medicare & Medicaid Services committed $1 billion to a multi-year effort that paying groups like state hospital associations to help networks of individual hospitals reach specific goals for patient harm reduction. According to a CMS analysis, the Partnership for Patients slashed what are termed “hospital-acquired conditions” 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’s no question that monetary incentives vastly outperformed eloquent professional exhortations about “first, do no harm.”
Make that “substantive” incentives. Since 2008, the federal government has required hospitals to report certain hospital-acquired conditions, such as leaving in a “foreign object” after surgery, and said Medicare won’t pay for extra care necessitated by this type of lapse. Although the HAC list has grown, its impact on patient harm has been puny.
“Non-payment for preventable harm is limited and hospitals still get paid for the majority of the hospital admission,” noted Dr. Tejal Gandhi, a veteran of a quarter-century in patient safety, when I reached out for her perspective. “The amount of dollars at risk is negligible.”
Driving Real Change
Let me switch gears here. As someone who grew up in a Jewish family with a strong New York connection — my maternal grandfather, like Lutnick’s paternal grandfather, owned a laundry and dry cleaning business in Manhattan – I ended up feeling a personal connection to Lutnick. And I’ve had a small, personal experience with a family member’s medical error, 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.
(A quick note: The family suffered further devastation in the terror attacks of 9/11 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.)
While you’re Commerce Secretary, not Secretary of Health and Human Services, you’re not shy about speaking up. And you also have the president’s ear. HHS Secretary Robert F. Kennedy, Jr. and CMS administrator Dr. Mehmet Oz are strong proponents of consumerism, but consumerism doesn’t work without reliable information. The best hospital-specific patient safety information today comes from the ratings of the Leapfrog Group. While they’re not perfect, they have nonetheless consistently used reputational risk to drive change. (By the way, Syosset Hospital now has an “A” Leapfrog grade.) Government needs to encourage this kind of effort.
More broadly, the government should help tear away medical error’s 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 Patients for Patient Safety. The OIG investigation of hospital non-reporting simply reinforces what activists have known for years about the industry’s “see no evil, hear no evil, report no evil” tendency.
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 actual examples, and I could go on. Moral repugnance obviously hasn’t worked; let’s give losing or making money a chance to weigh in.
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: “Grab them by their wallets, and their hearts and minds will follow.”
