Remembering Lucian Leape: Reflections from his colleagues and friends

Remarks from our Executive Director

Lucian Leape made the world a better place. He was a steadfast supporter of the Betsy Lehman Center, and I can say in all sincerity that the Center would not be what it is today without his wisdom, collegiality and generosity.

I came to the Center in late 2013 with deep knowledge in a variety of health policy issues but limited experience specific to patient safety. To get up to speed, I depended on the many people who made introductions and offered advice on the unique role the Center could play. Above all, I am grateful to Lucian. He and I had many thought-provoking conversations over the last decade and he was always willing to talk through challenges and offer guidance.

A highlight of my earliest days at the Center was the chance to interview Lucian for a video we produced to open our December 2014 launch event at the John F. Kennedy Library. We recently uncovered the unedited version of that hourlong filming session. Not surprisingly, it is replete with Lucian’s wisdom, which continues to resonate and inspire today. I know you will appreciate a brand-new cut of previously unseen footage below.

We proudly dedicate this issue of Patient Safety Beat to Dr. Lucian Leape, as we all continue the work about which he was so passionate.

Barbara Fain
Executive Director, Betsy Lehman Center for Patient Safety

Lucian Leape was a mentor and friend for so many years. Our early connections in patient safety inspired so much of our work at the Institute for Healthcare Improvement. I loved visiting him and his wife, Marty, as the conversations always produced new ideas for me! A short time ago, I went to his place to drop in for a visit and bring him his favorite dessert. We relived our long lives in improving health and care, and he inspired me to rethink the next generation of safety work. He wrote me a wonderful note after the visit and said, in part, “What matters today are the concepts of agency and community, meaning not just that every person feels it is safe to speak up, but that the environment is such that it is done every day among the team, which gets together every day to plan care. Every member, from doctor to housekeeper, is valued, listened to, talks about what is good and bad, and participates in care decisions. Community, where everyone feels regarded and respected by everyone else, is key. Value, agency and community, with meaningful patient-centeredness, is the basis for all decisions. That’s our leadership challenge!”

As always, Lucian’s wisdom and challenges will continue to inspire change for us all.

Maureen Bisognano
Emerita and Senior Fellow, Insititute for Healthcare Improvement

I was fortunate to be a member of the inaugural cohort of Harvard Medical School’s Quality and Safety Fellowship, and I’ll never forget when Dr. Lucian Leape met with just the four of us early on. It felt surreal — and powerful — that a Harvard surgeon was devoting himself to the uncharted field of patient safety. I later had the privilege of learning from him again during my MPH at the Harvard School of Public Health.

Now, nearly 15 years into my career at Harvard Medical School, promoted through the ranks while doing safety and quality research, I see how profoundly Lucian paved the way. His courage to speak uncomfortable truths, his insistence on systems thinking and his moral clarity gave us not only a language for safety, but also the conviction to act. As Chief Quality Officer of a large health system in Boston, I try to carry forward his legacy every day. There is still much work to do — but we are only here because he went first.

Yael K. Heher, M.D., M.P.H.
Chief Quality Officer, Beth Israel Lahey Health
Associate Professor, Harvard Medical School

I had the honor of working with Dr. Leape as a new nurse at The Floating Hospital. He was a wonderful surgeon and was dedicated to excellent patient care.

I was a little intimidated by him at first. As I became a young new nurse manager, we worked together to improve standards of care. This was way before the focus on quality and safety.

I would continue to see him at conferences through the years. He always recognized me and acknowledged my work — one of the best compliments in my career! I learned a great deal from his lectures.

I went on to become the CEO of Lawrence General Hospital. I made quality and safety a priority and included all staff, physicians and Board members in our journey for a risk-free environment.

I sincerely appreciate the opportunity to work with such a special, kind and brilliant physician. Through his influence, major progress has been made for high quality care.

Dianne J. Anderson R.N., M.S.
Former CEO and President, Lawrence General Hospital

Lucian Leape’s work has had a profound impact on my understanding and approach to patient safety. One of his most powerful statements, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes,” has stayed with me throughout my career. It continues to shape how I view human error and fuels my commitment to fostering a culture of learning, not blame.

His leadership helped shift the conversation from individual fault to system improvement, and for that, I am deeply grateful. His influence lives on in the work we do every day to make care safer.

Jody Langlois, B.S.
System Director of Risk Management, Patient Safety & Regulatory Affairs
Athol Hospital, Heywood Hospital & Heywood Medical Group

In 1995, I was the brand new Medical Director of Quality and soon to be one of the first Chief Quality officers in the country when I read Lucian’s article “Error in Medicine” in JAMA. Up until that point, medical error was not really discussed, as it was a taboo subject that implied individual failure. Lucian’s article not only created awareness for the problem of patient safety but highlighted how “the system” was responsible for facilitating most errors. I was blown away. Over the years, I had the opportunity to meet and work with Lucian on committees. His calm approach and the moral authority he brought to the field always inspired me to do more to improve patient safety.

Evan Benjamin, MD., M.S.
Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Harvard Medical School

Taking a class with Dr. Leape during my year at the Harvard School of Public Health changed how I thought about improvement, measurement and patient safety. In his long career Lucian Leape inspired many like me, and he also challenged the establishment’s thinking that errors and harm in healthcare were unavoidable.

Joshua Allen-Dicker, M.D., M.P.H.
Internist and Associate Chief Quality Officer, Cornell Campus of New York-Presbyterian Hospital

Lucian was a true icon and a kind and generous human being. I would reach out to Lucian when I needed courage to do something at MHQP that I knew would be gutsy; he was always there for me and very supportive. I will miss him.

Barbra G. Rabson, M.P.H.
President and CEO, Massachusetts Health Quality Partners

I met Dr. Leape in my early days of working on patient safety, and I was always impressed by his direct, articulate and passionate support of transparency with patients, families, clinicians and the importance of involvement of governance in appreciating and mitigating the risks for patient harm. When Dr. Leape spoke in a meeting at the Mass Coalition or a National Patient Safety Foundation/Lucian Leape Institute meeting, I learned to listen carefully to his language choice so that I could think about crafting my messaging to encourage improvement!

Pat Folcarelli R.N., Ph.D.
Senior Vice President for Patient Services and Chief Nursing Officer, Beth Israel Deaconess Medical Center

Lucian remained engaged in the work of the Lucian Leape Institute and in advocating for patient safety until his death. At the age of 91, he brought former nurse RaDonda Vaught to a virtual LLI member meeting to share her experience facing criminal prosecution for a medication error that resulted in the unfortunate death of a patient. He was deeply concerned that, despite having acknowledged her error, RaDonda ultimately bore the brunt of blame, without the visible support of her organization, despite evident system flaws. At the age of 91, he fiercely advocated for health care to do the right thing…that’s passion.

In 2015, I traveled with Lucian to meet the CEO of a trade association to gain buy-in on a proposal for their members to invest in patient safety. The CEO pushed back on the proposal, and the conversation became “energetic.” Lucian implored, “Of course, you should invest in safety. It’s morally right, and you and your members stand to benefit from investing in and supporting safety.” The meeting ultimately ended without the CEO’s support, and Lucian was very frustrated. During our taxi ride to the airport, attempting to redirect the conversation to a more positive subject, I excitedly shared that we were introducing a new award for nurses and their contributions to patient and workforce safety at the upcoming Patient Safety Congress. I was caught off guard when he responded, “Do you really want to know what I think about awards for patient safety??!! We shouldn’t have to give awards for patient safety!! That’s our job.” Despite his strong feeling that health care should not have to give awards for care to be safe, he added, “I suppose if it’s for nurses, then it’s okay.”

Whether writing his book or engaging in everyday conversations, Lucian was consistently the first to honor the contributions of others while shunning the limelight himself. He was also a stickler about honoring history and the people who made a difference — and he spared no words when he felt that the work of key individuals or organizations had not been properly acknowledged. This wasn’t about nostalgia or being gratuitous. He deeply felt that people mattered and deserved recognition and respect. I think this is one reason why he had such incredible synergy with LLI member Paul O’Neill. I had the honor of meeting both on my first day of work with the National Patient Safety Foundation at the LLI Expert Panel Roundtable that produced Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Healthcare. That day remains one of the most important and influential days of my career. In hindsight, I wish we had audio recordings of that meeting, which should be required listening for all current and future health care leaders.

Patricia A. McGaffigan, R.N., M.S.
Senior Advisor, Patient and Workforce Safety, Institute for Healthcare Improvement

Lucian was the gift that kept giving to a health journalist like me.

He held my hand back in 1999, when I wrote a four-part series on hospital errors for The Boston Globe, ensuring I understood that to err is human and generally is a result of the failure or lack of safety systems. It was the longest series of its kind any paper had done back then, and it might never have happened — and certainly wouldn’t have gotten it close to right — if not for the wise Dr. Leape.

After that newspaper series, I did a series of talks at hospital grand rounds, medical society meetings and other venues nationwide about medical errors and journalists’ role in rooting them out. Lucian arranged several of those talks, joined me at a few and supported me throughout.

A couple of years later, I left the Globe and launched a health journalism fellowship that is entering its 24^th year. Each year, we bring 13 of America’s best to Boston for nine days/nights of training on issues ranging from pandemics and mental health to medical errors. Lucian was a regular speaker and, as always, an inspiration.

I had wrist surgery last month and was dazzled by how many times I was asked my name, date of birth and what joint should be operated on. To most patients, those questions would have seemed obsessive and unnecessary. To me, they were a welcome sign of now-standard procedures for ensuring the right operation is being done on the right limb and the right patient. All thanks, in substantial measure, to the patient safety movement fathered by Lucian Leape.

And it wasn’t just in his role as a doc and guru of hospital quality that he was a gift to me. I also write books, and for most of my nine, I’ve done talks at Brookhaven, his Lexington retirement community. He was my de facto host at each. It helped that I knew well from my year as a Nieman Fellow at Harvard, Lucian’s bride, Martha, the head of career services, who was Lucian’s match as smart, gracious and inspiring.

Lucian, I already miss your wide-as-the-moon smile, your never-quite-satisfied inquiring mind, and your belief that, despite the naysayers, journalism can be a force for good and for making health care safer.

Larry Tye
Director, Health Coverage Fellowship Center for Health Communication, Harvard T.H. Chan School of Public Health

Lucian Leape was a giant in the field of patient safety and really led the movement in the early days. It was so important to have a physician surgeon talk about errors and harm and how health care needed to be better. And to do so with research and data, as well as passionate opinion pieces and talks.

I had the good fortune to know Lucian from the start of my career, and he was one of my first mentors. I was a fellow in general medicine at Brigham and Women’s and was looking for projects. My formal mentor suggested I go talk to this faculty member at the Harvard School of Public Health, so I made an appointment and knocked on his door! That person was Lucian, and I helped him write a paper on reducing adverse drug events through breakthrough collaboratives. Don Berwick was the senior author. It was quite an opportunity, and Lucian continued to generously mentor me as well as many other safety leaders along the way.

It was also an incredible honor for me to have served as president of the Lucian Leape Institute, which was founded by the National Patient Safety Foundation. The institute serves as a leading voice for safety, and with Lucian as its guiding force, it led work to advance many key issues such as patient engagement, workforce safety, transparency and safety culture. Lucian will be incredibly missed, but his legacy will live forever, as well as his profound impact on so many patients and safety professionals.

Tejal Gandhi, M.D., M.P.H.
Chief Safety and Transformation Officer, Press Ganey Associates LLC

Lucian made so many contributions to patient safety, which was barely on the radar screen as an issue when he was part of the Harvard Medical Practice Study team, led by Troy Brennan and Howard Hiatt, that published the results of a seminal study showing that safety related to medical care was a major cause of harm in the U.S. He was also a key member of the Institute of Medicine committee that released To Err Is Human, which brought the problem into the public eye.

Later, I worked with Lucian on the Adverse Drug Event Prevention Study, which was the definitive work on medication safety in the hospital at that time. We did a series of studies showing the magnitude of harm caused by medications, as well as how it could be prevented.

Lucian also funded the Lucian Leape fellowships through ISQua, the International Society for Quality in Health Care, which has trained leaders in patient safety in transitional countries. He was central to helping us establish the Center for Patient Safety Research and Practice at Brigham and Women’s.

Overall, he was one of the most important figures in patient safety in the U.S. and globally. And he had little patience with the status quo. He was always seeking ways to make care safer.

David W. Bates, M.D., M.Sc.
Executive Director, The Center for Patient Safety Research and Practice, Brigham and Women’s Hospital
Medical Director of Clinical and Quality Analysis, Mass General Brigham

I’ve struggled to find the right words to honor Lucian, our friend, colleague, mentor, visionary leader, and one of the kindest, funniest, and most gracious people I’ve ever known.

I feel fortunate to have learned so much from him over the years and to have felt so supported in our work at the Massachusetts Coalition for the Prevention of Medical Errors, where Lucian played central roles as a founder, teacher and active participant.

I always appreciated his response to presentations:

First the sincere, gracious and insightful compliment,
then the challenging question — not challenging the presenter, but our thinking, noting some orthodoxy that we should uproot,
often delivered with raised eyebrows and his impish chuckle.

In his writing, presentations and discussions, Lucian made us think really deeply. He pushed us to examine our sclerotic assumptions and behaviors, our faults and failures in health care, and to be bold in change for improvement.

I learned from others in our work that “Leadership is about keeping the main thing, the main thing.” Lucian, the incomparable leader, kept us focused on the main thing: health care is about health and about caring, for patients and families, and for our workforce. He showed us that we must acknowledge our faults and failures and continually address the values and systemic obstacles that stand in way of safe care.

Paula Griswold, M.S.
Executive Director, Massachusetts Coalition for the Prevention of Medical Errors

I remember feeling intimidated the first time I asked Lucian for a favor. I met with him at Harvard and asked him to be the keynote speaker at the annual dinner for MITSS (Medically Induced Trauma Support Services), the organization I founded in 2002. I was delighted when he said yes. But he also said something to the effect of, “But, Linda, wait a minute. You know, I see you around, I know we’ve worked on a few things together, but I’d like to know a little more about who you are.” I was shocked that this patient safety giant wanted to know more about me. The thing I remember most about that first meeting was his reminding me that everybody puts on their pants one leg at a time, meaning that we’re no different. I had never had someone at that level be so down-to-earth and level with me in that way.

I’ll also never forget the bond Lucian formed with my then 12-year-old daughter, Lindsay, at the National Patient Safety Foundation’s annual Congress in 2007. I stopped Lucian in the hallway to introduce him to my husband and Lindsay. He was carrying a copy of Time magazine with a photo of Barack Obama on the cover. Lindsay, who’s always been politically precocious, asked Lucian if he’d read the article. One thing led to another, and soon Lindsay was offering Lucian one of the Obama campaign pins she’d picked up earlier in the day. Lucian was so engaging and gracious with Lindsay! He immediately put the button on his lapel and wore it all day, including while he gave a keynote address. That experience solidified my view of Lucian as a good man. He was a giant in patient safety, but relationships were still meaningful to him, even with a young girl he’d just met. And he wasn’t afraid to speak his mind, nor to let others speak theirs, in plain language we all can understand.

I was honored that Lucian agreed to serve on the MITSS Board of Directors in the early years. He attended a long board retreat we held, starting with dinner one night and extending through the entire next day, to work on a new strategic plan. Afterward, he said he found the meeting to be useful and that, understanding more about the mission and purpose of MITSS, felt he could be more helpful. Later on, he fully supported the decision to continue MITSS work as part of the Betsy Lehman Center.

Lucian was a great friend to me, my organization and so many others. With his strength and kindness, he set an example that will be difficult to match.

Linda Kenney
Director of Peer Support Programs, Betsy Lehman Center for Patient Safety

As part of a then-younger generation of clinicians trying to improve quality, I discovered several of Lucian’s pre-patient safety articles on unnecessary surgery and surgical appropriateness assessment (1989−1993). Their originality and relevance were immediately apparent, and I began using them to teach residents rotating through the surgical consult service on which I attended.

Little did I realize that Lucian’s work, as he transitioned from being a pediatric surgeon to a RAND health services fellow to working on the Harvard Medical Practice Study, would change my life. He became a role model, research project collaborator and, ultimately, a friend. I was privileged to visit with Lucian just a few days before his death, and although his health was failing, his magic sparkle and brilliance still shone through.

Along with people like Don Berwick, Paula Griswold and David Bates, Lucian created a critical mass of people, projects and thinking that ultimately drew me to Boston in 2007 after 35 years at Cook County Hospital in Chicago. In 2000, he kindly wrote a (likely decisive) letter of support for me, an inexperienced researcher he barely knew, as I applied for a grant to study diagnostic error:

If you can get just a few doctors willing to play this game to learn from diagnostic errors, and find out what you find out, you will make a big impact. I would dearly love to see a systematic, blame-free, intellectually curious, everyday-that’s‑the-way-we-do-business approach to diagnostic errors, in which people accept their likelihood and sincerely participate in activities to reduce them.

The nugget here, and what I consider Lucian’s greatest contribution to patient safety and patients, were those two words: “blame free.” He understood and taught us that once you stop focusing on blame, you immediately clear away defensiveness and cover-up and provide a new space for learning, understanding, honest engagement, transparency and safety. He continually wrestled with the deepest ramifications of blame-free, never simply dismissing errors as “no-fault,” but instead working to delve deeply into the complex systems that include people (staff and patients), technology, working conditions, pride and health systems.

Speaking of health systems, Lucian was a strong supporter of single-payer health reform and served on the board of trustees of Cambridge Health Alliance, a public hospital that, like Cook County, represented a model for non-profit universal access and care.

And he thought about the future by meticulously documenting the past, writing a book about the first three decades of patient safety, which now has more than 400,000 open-access downloads, preserving key patient safety lessons for future generations.

Gordy Schiff, M.D.
Quality and Safety Director, Harvard Medical School for Primary Care
Associate Director, Brigham and Women’s Center for Patient Safety Research and Practice

Remembering Lucian Leape: Reflections from his colleagues and friends

Remarks from our Executive Director

Contributors