In the past two years Somerset Medical Center has sunk $12 million into a state-of-the art clinical information system to ensure patient safety, which has been alarmingly tied by two national studies in recent weeks to the nation's nursing shortage. But all the technology safeguards in the world couldn't protect the hospital and its patients from a nurse allegedly bent on harming his patients.
What's more, a safety net that relies heavily on communication between hospitals and local, state and national regulatory agencies apparently failed miserably to disrupt the cycle of bad hires at a string of hospitals where the nurse was employed-and in several instances fired-over a 16-year period.
"Absolutely the technology has not let us down; it has helped us identify this guy," said Dennis Miller, president and chief executive officer of the 269-bed Somerville, N.J., hospital. "But you can't prevent someone, no matter what you do, from doing criminal acts no matter how hard you try."
The horrific story unfolded in a New Jersey courtroom last week in leafy Somerset County, where Charles Cullen, 43, was charged with the attempted murder of a 40-year-old woman at the hospital on June 15, and the murder of a 68-year-old priest on June 28. In both cases, Cullen's weapon appeared to be lethal doses of the heart medication digoxin.
That could be the tip of the iceberg. Cullen, a registered nurse, has reportedly confessed to killing as many as 40 patients over the course of his 16-year career at some nine hospitals and a nursing home in New Jersey and Pennsylvania. Superior Court Judge Paul Armstrong-who, interestingly, represented Karen Ann Quinlan in her right-to-die case in the late 1970s-procedurally rejected Cullen's guilty plea. Investigators said Cullen might be responsible for 12 to 15 deaths at Somerset alone, where he worked from September 2002 until Oct. 31, when he was fired.
In the days since Cullen's Dec. 15 courtroom appearance, as the hospitals where he had previously worked revisited his employment history, the far-reaching investigation has unnerved the entire healthcare industry, revealing disturbing inequities in the way hospitals hire and fire their physicians and frontline professional workers. What is coming increasingly into focus is a fragmented employment system plagued with gaps and disconnects, sorely lacking in checks and balances, and crippled by the fear of litigation.
"Nurses tend to go under the radar screen. With all the focus on nurses, you don't have a peer-review system as there is for doctors," said Robert Conroy, a partner in the law office of Kern Augustine Conroy & Schoppmann and the attorney for the Medical Society of New Jersey. "Unfortunately, you have bureaucrats regulating nurses in the hospital setting and it's easier to just let some (nurses) resign, retire or move on to the next job rather than to conduct an investigation and take disciplinary action-all of which could result in an unlawful termination lawsuit."
The nursing shortage probably has only exacerbated the situation, Conroy said. Nurses are increasingly in managerial roles, overseeing paraprofessionals who are not likely to question their actions. They are increasingly transient as well. Some nurse-starved hospitals may be "willing to look aside, hold their breath and pray for luck," he said.
In November, the Institute of Medicine released a report that said hospitals put patient safety at risk by overworking their nursing staffs and using inexperienced nurses to cover understaffed units. Also last month, U.S. Pharmacopeia issued a report that connected poor working conditions for nurses to medication errors.
From the start, red flags that could have alerted hospital human resources departments to Cullen's heavily spotted employment record apparently were raised but never made it out of his personnel files. After graduating from Mountainside School of Nursing in Montclair, N.J., in 1987, Cullen went to work at St. Barnabas Medical Center in Livingston. He was employed full-time at St. Barnabas until 1989 and then continued there through an agency on a per diem basis until 1992, when he was fired, said Ellen Greene, a St. Barnabas spokeswoman. Greene said she could only comment on the dates of his employment, not the reasons for his termination.
Similarly, in August 1997, Cullen was fired from Morristown (N.J.) Memorial Hospital for poor performance after only nine months of employment, said Joan Lebow, a spokeswoman for Morristown's parent, Atlantic Health System. Still, prospective employers calling Morristown for a reference for Cullen after his termination would only have learned the dates of his employment-information that is no different from what Morristown typically receives when it makes inquiries, said Lynn Turner, director of total compensation and recruitment for Atlantic.
"The feeling is it's between us and the individual, and it is really getting back to the fear of liability," Turner said. "I see this as a much bigger issue going forward. The government is going to have to review, and I guess protect us to a certain extent, if we go ahead and share with other organizations anything derogatory about an individual."
By the time Cullen arrived at Somerset's doorstep five years and some four hospitals later, nothing was askew in his employment record, Somerset officials said. Only in the last week has it come to light that just three months before he was hired at Somerset he had resigned under a cloud of suspicion from St. Luke's Hospital in Bethlehem, Pa. Cullen, who worked at St. Luke's from June 2000 until June 2002, was thought to be responsible for some unused medication that was found in a locked needle-refuse bin, said Susan Schantz, a St. Luke's spokeswoman.
The incident unleashed an exhaustive investigation involving an independent cardiologist, the state board of nursing and the Pennsylvania State Police, she said. The hospital reviewed 69 deaths in the coronary-care unit where Cullen worked in a six-month period. Nothing conclusive was ever found, Schantz said. As a result, when Somerset called St. Luke's for a reference, Somerset received only a "neutral reference" that verified his dates of employment.
"There is no definitive proof that he did divert the medication," Schantz said. "There is literally nothing else we could have done." Nevertheless, had Somerset made a written request for information along with a signed consent form from Cullen, the recruiters would have learned that Cullen had a "no rehire" on his personnel file, Schantz added. "I think by any standard that would raise flags, but you can't condemn anyone without evidence," she said.
Indeed, Miller said Somerset's policy on references is just like every other hospital's, essentially confirming employment dates. "That is technically all we are allowed to tell people. We can be sued for giving out information for defamation of character," Miller said.
In another example of the poor communication between hospitals, in late November, Cullen was seeking employment at Muhlenberg Regional Medical Center in Plainfield, N.J. Somerset never responded to Muhlenberg's inquiry for an employment reference, but Cullen was not offered a position for other reasons, said Mark Hendrikson, a spokesman for Muhlenberg's parent, Solaris Health System. Miller vehemently denied that, saying voice messages were exchanged between nurse recruiters and that Somerset's chief nursing officer eventually relayed the circumstances of the termination to a colleague at Muhlenberg "to make sure he would not work again."
"This is a total systemic issue," said William Cors, Somerset's chief medical officer. "We're told 95% of the reference checks we do result in name, rank and serial number. We ask all of them if they would rehire the person and I'm told 95% of the time that question is declined."
The system is very different for doctors, Cors said. Written references with answers to specific questions are required of all physicians seeking privileges at Somerset. Hospitals are under a federal mandate to check the practitioner databank for reportable actions against doctors every two years as part of their credentialing process. Cors said he only recently heard that there is a federal databank for nurses. "I'll tell you, it's one of the better kept secrets in healthcare," Cors said.
The National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank, which includes nurses, were created with very different intentions, said Mark Pincus, acting director of policy and of practitioner databanks for the federal Health Resources and Services Administration. The practitioner database, which opened in 1990, is a repository for all state licensure actions and clinical privileging actions as well as any actions taken by professional societies, Medicare and Medicaid against primarily doctors and dentists. The databank is accessible to hospitals, managed-care organizations and other healthcare organizations.
The Healthcare Integrity and Protection Data Bank, on the other hand, was created to guard against fraud as part of the Health Insurance Portability and Accountability Act of 1996 and encompasses a much smaller universe, Pincus said. Though it's a repository for licensing and certification actions, healthcare-related civil actions and criminal convictions against all types of practitioners, suppliers, hospitals and healthcare facilities, only health plans and federal and state agencies can both report the information and access it. Judging by what he's read about the charges against Cullen, there "weren't any reportable actions taken against him" that would be included in the database, Pincus said.
Beatrice Crofts Yorker, a nurse and lawyer who directs the School of Nursing at San Francisco State University, has studied serial murders in hospitals since 1986. She has documented cases involving 42 serial killers internationally and is researching another 30 cases. "The body count is well over 500," Yorker said. At least 26 of the cases occurred in hospitals and 35 of the perpetrators were nurses. Only two cases involved doctors, the most recent being Michael Swango, who in 2000 pleaded guilty to killing three patients in a Long Island, N.Y., hospital but is suspected of killing more patients elsewhere. He was sentenced to life in prison without the possibility of parole (Oct. 16, 2000, p. 58).
"Hospital risk management needs to focus more on patient safety and focus less on disgruntled nurses who were denied employment. There needs to be a database for unsafe nurses," Yorker said.
One bad apple erodes the trust in the entire profession of 2.7 million nurses, but in most cases it is other nurses who blow the whistle on their errant colleagues, said Cindy Price, a spokeswoman for the American Nurses Association. Though the ANA has no influence in the hiring of nurses, the trade group strongly recommends that hiring managers check reference and support systems. "We encourage employers to work collaboratively with state licensing boards to develop mechanisms for documenting and gathering data of this nature," Price said.
In the wake of the Cullen allegations, New York Gov. George Pataki has proposed legislation to strengthen background checks of healthcare workers.
Miller said he has made it his mission to seek reform at all levels to ensure that employers can speak freely about rogue employees without fear of a lawsuit. "Hopefully there will be an outcry for national reform to make sure somebody like this can never do this again," he said. "This is not a New Jersey issue and it's not a Pennsylvania issue. This is a national issue."
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