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Systematic failures allowed nurse to kill undetected

Patient Safety Monitor Alert, March 4, 2004

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Charles Cullen, the night shift nurse who says he has killed at least 40 people during his 16-year nursing career, may be one of the most prolific serial killers in American history. Systems failures and gaps in oversight at the hospitals where he worked may have allowed him to earn that title, according to a February 29 report published in the New York Times.

There were red flags along the way that warned of an unstable person with a capacity to harm himself or others. Yet for years he was able to move from one job to the next without arousing too much suspicion.

The following are some of the system failures that allowed him to allegedly kill undetected, according to the Times article: 

•  More than 10 years ago, a medical examiner failed to order a test for a patient who died. The patient may be one of his victims. A separate coroner believed that a death was not accidental but failed to alert police.
  
• Employers did not report Cullen to oversight agencies, law enforcement, or each other, usually because they were not required to. Some even brushed off allegations that were made by victims' families or coworkers. In one instance, a cancer patient complained that Cullen injected her with something that her physician hadn't ordered. Although the patient's relatives complained to physicians, no one took action. The elderly patient was discharged the next day and died of heart failure the same afternoon.
   
• Cullen worked on units where death is commonplace, such as on cardiac and intensive care units. As a result, he had access to a range of dangerous drugs at a moment's notice.
   
• Nursing shortages hindered some hospitals from scrutinizing Cullen's work history more carefully. He often sought work on night shifts, where he worked on units with little supervision and few coworkers. In fact, other medical serial killers have also favored working on overnight shifts on units with the sickest patients. 
   
• A hospital's computer system showed that Cullen had accessed digoxin from his unit's Pyxis system for one of his patients-even though the patient had not been prescribed the drug. He allegedly gave it to another patient to which he was not assigned.
  
  The patient suffered a sudden, life-threatening heart malfunction and died three months later. Her blood tests showed high levels of digoxin, even though she had never been prescribed the drug. Hospital officials didn't connect Cullen to the event, however, because nurses took incorrect medications from the Pyxis machine every day, according to the hospital's director of medicine.  

State lawmakers are trying to find ways to improve a hospital's ability to detect, and do something about, troubled employees.

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