'He was killing throughout'

Editor's note: In The Good Nurse, journalist Charles Graeber chronicles the story of critical-care nurse Charles Cullen, who killed more than three dozen patients at nine hospitals in New Jersey and Pennsylvania during the course of a 16-year career. Those are the deaths that can be proved—experts Graeber interviewed say the real toll may be much higher and never known. The book documents repeated failures by hospital administrators to stop Cullen as suspicions arose from a pattern of poisonings, unaccounted doses of lethal medications and electronic records that put Cullen at the scenes of the crimes. Modern Healthcare reporter Joe Carlson talked to Graeber about what he learned from six years researching the book, interviewing dozens of firsthand witnesses and participants, including jailhouse interviews with the killer himself. Here is an edited excerpt:

Joe Carlson: Why do you think it is so hard for executives, lawyers and administrators at hospitals to go to the police at the first sign of an intentional killing, let alone a pattern of killings?

Charles Graeber: I have to be very fair in saying that it's beyond the imagination, or at least requires a great deal of imagination for any administrator, let alone anyone else, to ever think that their nurses are killing their patients. That's not the first thought that comes to mind, certainly not that it's intentional, certainly not that you're dealing with a serial killer.

The other larger point, though, is that hospitals are businesses. They have a tendency to become worlds in themselves, shut off from the outside trying to deal with their problems internally, and largely for fear of—were it to ever go external—liability. And liability is a real concern.

Carlson: “60 Minutes” had a feature on this story recently, and they were able to interview Cullen as well, and I was struck by some of his words. Cullen said, “I think you can say I was caught at St. Barnabas and I was caught at St. Luke's. There's no reason that I should have been a practicing nurse at that point.” Yet he left St. Luke's without even so much as a bad job reference and went on to kill more than a dozen other people. Is it fear of negative publicity, or is it this fear of litigation?

Graeber: That's part of what took so long researching this book—really trying to lay those facts out cleanly, so that the reader could decide, the public could finally understand what that process was. When I started meeting with Charlie Cullen a little more than six years ago, he was very upfront about the fact that he had been caught before, particularly at those hospitals. There were several other instances.

Sixteen years and nine hospitals, a lot happened to him and he was killing throughout. But the St. Luke's example is, I think, a particularly onerous one. That was more than a failure of imagination, I think. He was caught stashing empty bottles of dangerous drugs at night. They knew that it was him that had been doing it repeatedly. The other nurses were very concerned about the mortality rates. The administration has since denied that aspect. They confronted him, allowed him to leave that same night with neutral references and didn't report it.

Carlson: “A lot has been made of the fact that the hospitals didn't seem to warn one another about Cullen during the job screening process because of legal repercussions for giving out bad references. Isn't there any legal risk in not telling another hospital that their job candidate was let go for reasons like suspected harm to patients or even just misuse of medications?

Graeber: The neutral reference is a standard corporate policy throughout many industries, and the reason is fear of being sued for libel. And the flipside of that is you don't want to be blackballed because of some interpersonal issues that have nothing to do with true job performance. It's a matter of trying to shift the power, or keep the power, from being entirely in the hands of either side, particularly in a small community. Having said that, they are completely abused here, and there is a liability in not informing a hospital if you suspect someone's been harming your patients.

The hospitals maintain that they did not have reason to believe that Charles Cullen was harming any of their patients. St. Luke's Hospital did report eventually to the nursing board that they couldn't say for sure what he had been doing with these diverted medications.

Carlson: “It seems like that might be a conflict of interest, though, to expect a hospital to do a thorough internal investigation to dig out information that could eventually be used to harm its reputation.

Graeber: Absolutely. It's a horrific situation all around for all involved. You don't want the killer to be there. You don't want anyone to have been harmed. You don't want to harm the reputation of a fine hospital or endanger the jobs of the fine men and women who work there and work hard there every day saving lives, or to wrongly accuse somebody.

Carlson: In an excerpt from your book that concerns Dr. Steven Marcus, who at the time was the director of New Jersey Poison Control, you write: “Marcus knew of several cases in which hospital staff members had poisoned patients—some in the literature, others that he had worked on personally. They called these killers Angels of Death. All of those cases shared a simple but disturbing pattern. Each time the doctors treated the rash of crashing patients like a disease to be studied while the administration and the lawyers treated them as a potential lawsuit. The institution dragged its feet before calling the cops, and while they dragged, people died.”

Do you think there are other Charles Cullens working in hospitals today?

Graeber: I'd like to think not. I know that with some of the increases in technology, greater accountability for dangerous drugs and even nondangerous drugs—any drug in sufficient quantities is potentially lethal—and better oversight, that this is not a situation that we should be paranoid about. … But I don't think it's something that we can let our guard down for. And I'm hoping that this book will promote greater discussion on that same issue.

Follow Joe Carlson on Twitter: @MHJCarlson