On Letters and Lessons from Lucian

In 2012, I was gifted with an invitation to join the National Patient Safety Foundation (NPSF) as Vice President of Safety Programs. Amid the NPSF’s vast portfolio of offerings was patient safety’s crown jewel – the Lucian Leape Institute (LLI), formed in 2007 as a patient safety think tank that provides a strategic vision for improving patient safety. Since the merger of IHI and NPSF in 2017, that important work continues today at IHI.

My umbilical cord to Lucian’s work emerged years earlier across roles in the patient safety technology industry and intersections with the anesthesia patient safety community. The invitation to join NPSF was sweetened by the chance to learn from the strategic compass and tutelage of the LLI, and my first day of work coincided with a LLI roundtable where I had the chance to meet Lucian and experience him and the LLI in action. I’m one of countless individuals who have been guided by Lucian’s commitment to ensure the primacy of patient safety amid the complexity and competing agendas of health care.

Lucian was both a literal and figurative tower of courage and transparency. He challenged the status quo concept that harm to patients was an acceptable, collateral consequence of health care, and that the blame for preventable harm lies with individuals and not with the systems in which they work. He fiercely believed that the single greatest impediment to preventing errors in health care is that we continue to blame and punish people for making mistakes. He championed efforts to address the overlooked system and culture requirements that are necessary to realize and sustain safety for all. He was a scholar and gentleman who advocated for safe, reliable, and respectful care for all, delivered in healthy work environments and safe cultures with a workforce that realized joy and meaning in their work.

From the abundance of undeleted communications in my email inbox, and with gratitude to my IT team for not forcing their deletion, I’ve harvested some deidentified lessons and letters from Lucian: 

2022: Email on the need for greater oversight and accountability for safety when health care delivery organizations fall short on their obligations to ensure safe, transparent systems:

“As you know, I’m a ‘big stick’ guy. If we can’t have an FAA equivalent, the least we should be able to count on is the watchdogs watching.”

2021: Email on Lucian’s appreciation for supporting his book, Making Healthcare Safe: The Story of the Patient Safety Movement:

“My relationships with IHI and LLI over the years have been exceptionally productive and have meant a lot to me. We did a lot of good things together, and it has been so enriching for me to work with such wonderful people. Your support for my book is one more measure of what makes you special. Patient Safety needs a boost. I hope the book will help.” (This book is open access and available here)

2020: Email from Lucian requesting advice for his book dedication:

“Patricia, my plan is to dedicate the book: ‘To all of the nurses who care for us and strive to keep us safe.’ Edits welcome. Should I keep ‘all’? Fondly – and gratefully, really – Lucian (The final dedication reads: “To the nurses who care for us and strive to keep us safe.”)

2015: Email — Lucian’s response to an invitation for an honorary fellowship, and the importance of family:

“Dear Patricia: I really appreciate your efforts, unflagging support of me, and your commitment to patient safety. And it is great fun to work with you in all the stuff we are trying to do at NPSF and LLI. And our relationship is such that I can be frank with you about stuff like this. Which is: Although I am very appreciative, and humbled, by the prospect of getting an honorary fellowship in the XXX Academy, I'm not willing to give up a weekend to do it (I would have to stay over Saturday night). At my age, my days are numbered, and I've become much more protective of them. My wife and family, and our friends, and all the things I want to do are, to put it simply, more important to me.” 

2015: Conversation during a taxi ride in DC, when I excitedly shared that we had a new award for patient safety:

“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 what our job is." Despite his strong feeling that health care should not have to give awards for care to be safe, he then added, "I suppose if it’s for nurses then it’s ok.”

2015: Lucian’s comments to a CEO of a health care trade association during that same DC trip:

“Of course you should invest some of your profits in safety. It’s morally right and you and your members stand to benefit from investing in and supporting safety.”

2012: In conversation about the LLI patient safety roundtables:

“We will not have a patient safety roundtable without patients at the table.”

I’m one of many individuals who was inspired by Lucian to come to work every day remembering that health care exists to steward all patients safely through their lifelong encounters with it. Patients are central as coproducers of safety. As the parent and compass of the modern patient safety movement, Lucian has illuminated pathways to healing broken systems and cultures that harvest the best of what health care can and should be. I’m grateful for his boundless imprint as a remarkable mentor, colleague, and friend to patients and the health care community, and for the many lessons from Lucian that matter now more than ever.    

Patricia McGaffigan, MS, RN, CPPS, is IHI’s Senior Advisor for Safety, and President of the Certification Board for Professionals in Patient Safety.  

Photo by Debby Hudson on Unsplash

You might also be interested in:  

• IHI and LLI Honor the Life and Legacy of Patient Safety Luminary Lucian Leape, MD
• Making Healthcare Safe: The Story of the Patient Safety Movement
• IHI Lucian Leape Institute