In an earlier entry I presented Charlie Munger’s story where a hospital administrator had to be willing to absorb the ill-will, if he was to take the actions necessary to fix a badly malfunctioning department of the hospital. Another person willing to absorb the ill-will in order to reform medicine was Lucian L. Leape whose story is sketched in the passages quoted below.
(p. B21) Lucian L. Leape, a surgeon whose insights into medical mistakes in the 1990s gave rise to the field of patient safety, rankling much of the health care establishment in the process, died on Monday at his home in Lexington, Mass. He was 94.
. . .
In 1986, at age 56, Dr. Leape grew interested in health policy and spent a year at the RAND Corporation on a midcareer fellowship studying epidemiology, statistics and health policy.
Following his stint at RAND, he joined the team at Harvard conducting the Medical Practice Study. When Dr. Howard Hiatt, then the dean of the Harvard School of Public Health (now the Harvard T.H. Chan School of Public Health), offered Dr. Leape the opportunity to work on the study, “I accepted,” Dr. Leape wrote in his 2021 book, “Making Healthcare Safe: The Story of the Patient Safety Movement,” “not suspecting it would change my life.”
The most significant finding, Dr. Leape said in the 2015 interview, was that two-thirds of the injuries to patients were caused by errors that appeared to be preventable. “The implications were profound,” he said.
In 1994, Dr. Leape submitted a paper to The New England Journal of Medicine, laying out the extent to which preventable medical injury occurred and arguing for a shift of focus away from individuals and toward systems. But the paper was rejected. “I was told it didn’t meet their standards,” he recalled.
Dr. Leape sent the paper out again, this time to The Journal of the American Medical Association. Dr. George Lundberg, then the editor of JAMA, immediately recognized the importance of the topic, Dr. Leape said. “But he also knew it could offend many doctors. We didn’t talk about mistakes.”
Dr. Donald M. Berwick, president emeritus at the Institute for Healthcare Improvement in Boston and a longtime colleague of Dr. Leape’s, agreed. “To talk about error in medicine back then was considered rude,” he said in an interview in 2020. “Errors were what we call normalized. Bad things happen, and that’s just the way it is.”
“But then you had Lucian,” he added, “this quite different voice in the room saying, ‘No, this isn’t normal. And we can do something about it.’”
Dr. Leape’s paper, “Error in Medicine,” was the first major article on the topic in the general medical literature. The timing of publication, just before Christmas in 1994, Dr. Leape wrote in his 2021 book, was intentional. Dr. Lundberg knew it would receive little attention and therefore wouldn’t upset colleagues.
On Dec. 3, 1994, however, three weeks before the JAMA piece appeared, Betsy Lehman, a 39-year-old health care reporter for The Boston Globe, died after mistakenly receiving a fatal overdose of chemotherapy at the Dana-Farber Cancer Institute in Boston.
“Betsy’s death was a watershed event,” Dr. Leape said in a 2020 interview for a short documentary about Ms. Lehman.
The case drew national attention. An investigation into the death revealed that it wasn’t caused by one individual clinician, but by a series of errors involving multiple physicians and nurses who had misinterpreted a four-day regimen as a single dose, administering quadruple the prescribed amount.
The case made Dr. Leape’s point with tragic clarity: Ms. Lehman’s death, like so many others, resulted from a system that lacked sufficient safeguards to prevent the error.
. . .
Dr. Gawande said he believed it was the confidence Dr. Leape had acquired as a surgeon that girded him in the face of strong resistance from medical colleagues.
“He had enough arrogance to believe in himself and in what he was saying,” Dr. Gawande said. “He knew he was onto something important, and that he could bring the profession along, partly by goading the profession as much as anything.”
For the full obituary, see:
(Note: ellipses added.)
(Note: the online version of the obituary has the date July 1, 2025, and has the title “Lucian Leape, Whose Work Spurred Patient Safety in Medicine, Dies at 94.”)
Dr. Leape’s history of his efforts to increase healthcare safety can be found in:
Leape, Lucian L. Making Healthcare Safe: The Story of the Patient Safety Movement. Cham, Switzerland: Springer, 2021.