Howard Lutnick and his two siblings were just teenagers when a chemotherapy overdose killed their father, and, with their mother already dead from cancer, left them orphaned. (Photo by: GHI/Education Images/Universal Images Group via Getty Images)
Education Images/Universal Images Group via Getty Images
It was a small anecdote, buried in a lengthy profile in The New Yorker of Commerce Secretary 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, 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, 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.)
This combination of 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.
A decade later, research revealed minimal national progress in reducing patient harm, falling short of the ambitious goal set by the IOM, now known as the National Academy of Medicine, to cut patient harm in half within five years.
In contrast, the Centers for Medicare & Medicaid Services allocated $1 billion to a multiyear initiative that involved incentivizing groups like state hospital associations to assist networks of hospitals in achieving specific patient harm reduction goals. According to a CMS analysis, the Partnership for Patients successfully reduced “hospital-acquired conditions” by 17% between 2010 and 2013, preventing an estimated 50,000 deaths and saving approximately $12 billion in healthcare costs. Monetary incentives proved to be more effective than mere professional exhortations to prioritize patient safety.
Dr. Tejal Gandhi, chief safety and transformation officer at Press Ganey, highlighted the limited impact of non-payment for preventable harm, as hospitals still receive payment for the majority of hospital admissions, with negligible financial risks involved.
To drive real change and prevent devastating losses like those experienced by families affected by medical errors, it is essential to prioritize reliable information and transparency in healthcare. Supporting initiatives like the Leapfrog Group’s hospital safety ratings and advocating for consumer reporting of adverse events can enhance accountability and promote patient safety.
Additionally, increasing financial incentives for providers to invest in technologies and practices that improve patient safety can have a significant impact. By aligning financial incentives with healthcare outcomes, providers may be more motivated to prioritize patient safety practices that have proven effectiveness.
Ultimately, a combination of financial incentives, transparency, and accountability can drive significant improvements in patient safety within the healthcare system. By incentivizing providers to prioritize patient safety and holding them accountable for adverse events, we can work towards a healthcare system that prioritizes patient well-being above all else. Please rewrite the following sentence: “The cat jumped onto the table and knocked over a vase.”
The feline leaped onto the tabletop, causing a vase to topple over.
