ANA Response to the Cullen case

  1. response from:
    american nurses association
    january - 2004

    protecting patients from unethical, incompetent and criminal acts
    by health care practitioners


    * any incident where a nurse intentionally harms a patient is of great concern to the american nurses association (ana) because it erodes the public's trust in the profession. however, given that rns comprise the largest of the health professions at 2.7 million strong, we must emphasize how rare this is. nurses have a history of caring for all patients in the most dire of circumstances, including wars, epidemics and natural disasters. tragically, other caring occupations such as volunteer firemen, law enforcement officers and physicians also must cope with the aberrant behavior of a few dangerous people who take advantage of their position.


    * in most cases, nurses are the ones who have blown the whistle and brought the problem of increased deaths, or an employee who is associated with an unusually high number of cardiac arrests, to the attention of authorities. this is in accordance with the code of ethics for nurses, which states: "as an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy." every nurse has a personal obligation to uphold and adhere to the code and to ensure that nursing colleagues do likewise. (code of ethics for nurses with interpretative statements, american nurses association, 2001)

    * the code of ethics for nurses specifically prohibits actions with the sole intent of ending a patient's life. according to the code, "the nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. however, nurses may not act with the sole intent of ending a patient's life, even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. this position is further clarified in ana's position statement regarding the promotion of comfort and relief of pain in dying patients (see http://nursingworld.org/readroom/pos...ics/etpain.htm for details).

    * ana has long been a proponent of "whistleblower" laws - at both the state and national levels - that would prevent employers from taking retaliatory action against nurses through actions including suspension, demotion, harassment or discharge for reporting improper quality of patient care. across the nation, nurses are speaking out or "blowing the whistle" against workplace conditions that jeopardize patients and staff and they need legal protection. with the restructuring of health care and its cost cutting measures, nurses are frustrated as they try to provide quality patient care while staffing levels, resources and support are often inadequate. see nursingworld.org/gova/state.htm for details on specific state information. on the federal level, ana has supported several bills over the last few years that include whistleblower protections for nurses. these include the rn safe staffing act (s. 991), the quality nursing care act (h.r. 3656), the patient safety and quality improvement act (s. 720 and h.r. 663), the safe nursing and patient care act (s. 373 and h.r. 745) and the bipartisan patient protection act (s. 1052).


    background on the cullen case

    a registered nurse (rn), charles cullen, was charged with one count of murder and one count of attempted murder of two patients at the somerset medical center, somerset, nj, in december 2003. the investigation that led to the arrest of mr. cullen was started after a nurse practitioner pursued a report from icu nurses about abnormally high levels of the drug digoxin in a patient's blood. according to news reports, mr. cullen has claimed to have killed as many as 40 patients during his 16-year career as an rn licensed in pennsylvania and new jersey. over this period, mr. cullen was employed in 10 different hospitals and was fired at least five times.


    regulation: reporting of nurses' infractions


    * boards of nursing in 36 states require a criminal background check on potential licensees. however, state regulations vary on whether a criminal background check is done based on the type of application: licensure by examination; licensure by endorsement; renewal of license; or reinstatement. (2000 national council of state boards of nursing, profiles of member boards)

    * all state boards of nursing (except guam) review felony convictions as part of the licensure application. (2000 national council of state boards of nursing, profiles of member boards)

    * while reporting requirements vary from state to state, the national council of state boards of nursing's model nursing practice act suggests that all employers of rns, licensed practical/vocational nurses or advanced practice rns report to the state board of nursing any individual whose employment has been terminated or has resigned in order to avoid termination for the following actions: failure to meet requirements; criminal convictions; fraud and/or deceit; revocation or action against a nurses license in another jurisdiction; unsafe practice/unprofessional practice; inability to practice safely, unethical conduct; misconduct; drug diversion; failure to comply with alternative program requirements (discipline); drug-related misconduct; or unlawful practice.

    * at the federal level, there are two government databanks - the national practitioner data bank (npdb) and the healthcare integrity and protection databank (hipdb) - where mandatory and voluntary reporting requirements exist for rns. data collected in these two databases may overlap or be cross-referenced, and there are sanctions against entities who fail to report the required information.

    * the national practitioner data bank serves as an alerting system designed to facilitate a comprehensive review of health care practitioners' professional credentials. when queried, the npdb signals state authorities and health care entities that there may be a problem with a health care practitioner. information reported to the npdb includes final actions for: medical malpractice payments; adverse licensure actions; adverse clinical privileges actions; adverse professional membership actions; and medicaid/medicare exclusion reports. with regard to rns, the only mandated reporting to the npdb relates to medical malpractice payments and medicaid/medicare exclusion reports. all other reportable information is voluntary when applied to registered nurses. specific to querying the npdb, it is not mandated that the health care entity seeking to license or hire the registered nurse query the database. the npdb does include a review and appeals process as a means of ensuring accuracy of the report.


    * the healthcare integrity and protection data bank was developed to combat fraud and abuse in health insurance and health care delivery. the hipdb database gathers information on final adverse actions taken with regard to: 1) any and all criminal action that is related to practice of one's profession; 2) health care fraud and abuse; 3) medicare and medicaid violations, sanctions and exclusions; and 4) state disciplinary action related to licensure. state boards of nursing are currently required to report final actions against a registered nurses license to the hipdb. as with the npdb, this database serves as an alert to government agencies and health plans that there may be a problem with a health care practitioner, provider organization or supplier.



    policy recommendations

    * protecting patients against potentially harmful actions by nurses, either intentional or unintentional, is a multilayered, multidimensional responsibility involving individual registered nurses and nurse managers and employers' human resources departments, as well as state and federal agencies.

    * with regard to national reporting, ana recommends that the reporting requirements for rns and other health professionals be the same as that for physicians and dentists (for whom reporting is already mandated). the reality is that employers must be held accountable when it comes to reporting information into these databanks and querying them prior to the hiring of nursing job applicants.

    * ana strongly recommends that any reported information be limited to final actions only. ana does not support the reporting of investigations that are still ongoing and in which no final action has been taken.

    * as with any new mandate, sufficient federal funding must be available to ensure the capacity of the databases to meet the additional burden that may result from this new requirement.

    * ana has long been a proponent of "whistleblower" laws that would prevent employers from taking retaliatory action against nurses through actions including suspension, demotion, harassment or discharge for reporting improper quality of patient care. such efforts may need to be broadened to protect registered nurses who report the unsafe practices of colleagues.

    * ana believes that regardless of which reporting or credentialing mechanisms are put into place - whether at the facility, state or national level - the principles of due process, dedicated to safeguarding the rights of the individual, and justice must be paramount.

    * ana has met with the staff of new jersey sens. jon corzine (d) and frank lautenberg (d), who have suggested they would sponsor federal legislation to address gaps in reporting of nurse information and will continue to monitor and shape initiatives at the federal level. ana also is monitoring the progress of proposed state legislation in new york and new jersey.

    ana contacts:
    cheryl peterson, senior policy fellow: 202-651-7089
    windy carson-smith, legal counsel: 202-651-7061
    erin mckeon, associate director, government affairs: 202-651-7098
    ana media contact: cindy price, 202-651-7038
    Last edit by NRSKarenRN on Feb 13, '04
    •  
  2. 7 Comments

  3. by   BarbPick
    Thank you for post this. There is nothing to comment on, the article says it all

    Barbara
  4. by   -jt
    How fast the legislature moves when the media reports someone died. In NY, our legislature responded to the staffing ratio bill NYSNA wrote but they passed only ONE piece of it so far --- staffing ratios for just liver transplant donors are now state mandated at 1:2. The liver transplant RECIPIENT (and every other pt) can just whistle dixie waiting for his nurse to try to care for him and a ton of others. The state didnt feel the need to pass the rest of the staffing ratio bill into law. Of course they moved so fast for ratios on liver donors because of the recent highly publicized death of one. Now, in response to the media exposure of Cullen's deeds, our Governor wants "RN Credentialing - to require employers conduct a thorough review and background check of every health professional providing care in institutions or clinics". He says "Every New Yorker should expect the best and most compassionate care every time they seek treatment. This new proposal will build upon the many steps we have taken to support this expectation."

    Ok thats fine. Doctors and dentists already are subject to this credentialing. No problem to add RNs. But what about the other propsals that we've also designed for pt safety - such as the safe staffing and banning mandatory ot bills???

    If our Republican Gov is so concerned about pt safety and the care pts receive in the hospital, how come he is not moving just as quickly on the staffing ratio bills and the mandatory ot bill. In the scheme of things, which one harms more pts - Cullens or poor staffing? How many Cullens do we come across? That nurse admits to causing the deaths of about 40 pts. But there are 98,000 preventable deaths in this country -- from medical errors that have been proven to partly be caused by unsafe staffing. But my state legislature seems to be saying "we're concerned about pt safety so lets all jump to tighten the rules to weed out the few and far between bad apples, but lets ignore the giant white elephant thats staring us in the face and is killing more people everyday than the likes of Cullen ever could".

    press conference: http://www.nysna.org/departments/com...liver_regs.htm
    Last edit by -jt on Feb 13, '04
  5. by   TartarSauce
    Quote from nrskarenrn
    response from:
    american nurses association
    january - 2004

    protecting patients from unethical, incompetent and criminal acts
    by health care practitioners


    * any incident where a nurse intentionally harms a patient is of great concern to the american nurses association (ana) because it erodes the public's trust in the profession. however, given that rns comprise the largest of the health professions at 2.7 million strong, we must emphasize how rare this is. nurses have a history of caring for all patients in the most dire of circumstances, including wars, epidemics and natural disasters. tragically, other caring occupations such as volunteer firemen, law enforcement officers and physicians also must cope with the aberrant behavior of a few dangerous people who take advantage of their position.


    * in most cases, nurses are the ones who have blown the whistle and brought the problem of increased deaths, or an employee who is associated with an unusually high number of cardiac arrests, to the attention of authorities. this is in accordance with the code of ethics for nurses, which states: "as an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy." every nurse has a personal obligation to uphold and adhere to the code and to ensure that nursing colleagues do likewise. (code of ethics for nurses with interpretative statements, american nurses association, 2001)

    * the code of ethics for nurses specifically prohibits actions with the sole intent of ending a patient's life. according to the code, "the nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. however, nurses may not act with the sole intent of ending a patient's life, even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. this position is further clarified in ana's position statement regarding the promotion of comfort and relief of pain in dying patients (see http://nursingworld.org/readroom/pos...ics/etpain.htm for details).

    * ana has long been a proponent of "whistleblower" laws - at both the state and national levels - that would prevent employers from taking retaliatory action against nurses through actions including suspension, demotion, harassment or discharge for reporting improper quality of patient care. across the nation, nurses are speaking out or "blowing the whistle" against workplace conditions that jeopardize patients and staff and they need legal protection. with the restructuring of health care and its cost cutting measures, nurses are frustrated as they try to provide quality patient care while staffing levels, resources and support are often inadequate. see nursingworld.org/gova/state.htm for details on specific state information. on the federal level, ana has supported several bills over the last few years that include whistleblower protections for nurses. these include the rn safe staffing act (s. 991), the quality nursing care act (h.r. 3656), the patient safety and quality improvement act (s. 720 and h.r. 663), the safe nursing and patient care act (s. 373 and h.r. 745) and the bipartisan patient protection act (s. 1052).


    background on the cullen case

    a registered nurse (rn), charles cullen, was charged with one count of murder and one count of attempted murder of two patients at the somerset medical center, somerset, nj, in december 2003. the investigation that led to the arrest of mr. cullen was started after a nurse practitioner pursued a report from icu nurses about abnormally high levels of the drug digoxin in a patient's blood. according to news reports, mr. cullen has claimed to have killed as many as 40 patients during his 16-year career as an rn licensed in pennsylvania and new jersey. over this period, mr. cullen was employed in 10 different hospitals and was fired at least five times.


    regulation: reporting of nurses' infractions


    * boards of nursing in 36 states require a criminal background check on potential licensees. however, state regulations vary on whether a criminal background check is done based on the type of application: licensure by examination; licensure by endorsement; renewal of license; or reinstatement. (2000 national council of state boards of nursing, profiles of member boards)

    * all state boards of nursing (except guam) review felony convictions as part of the licensure application. (2000 national council of state boards of nursing, profiles of member boards)

    * while reporting requirements vary from state to state, the national council of state boards of nursing's model nursing practice act suggests that all employers of rns, licensed practical/vocational nurses or advanced practice rns report to the state board of nursing any individual whose employment has been terminated or has resigned in order to avoid termination for the following actions: failure to meet requirements; criminal convictions; fraud and/or deceit; revocation or action against a nurses license in another jurisdiction; unsafe practice/unprofessional practice; inability to practice safely, unethical conduct; misconduct; drug diversion; failure to comply with alternative program requirements (discipline); drug-related misconduct; or unlawful practice.

    * at the federal level, there are two government databanks - the national practitioner data bank (npdb) and the healthcare integrity and protection databank (hipdb) - where mandatory and voluntary reporting requirements exist for rns. data collected in these two databases may overlap or be cross-referenced, and there are sanctions against entities who fail to report the required information.

    * the national practitioner data bank serves as an alerting system designed to facilitate a comprehensive review of health care practitioners' professional credentials. when queried, the npdb signals state authorities and health care entities that there may be a problem with a health care practitioner. information reported to the npdb includes final actions for: medical malpractice payments; adverse licensure actions; adverse clinical privileges actions; adverse professional membership actions; and medicaid/medicare exclusion reports. with regard to rns, the only mandated reporting to the npdb relates to medical malpractice payments and medicaid/medicare exclusion reports. all other reportable information is voluntary when applied to registered nurses. specific to querying the npdb, it is not mandated that the health care entity seeking to license or hire the registered nurse query the database. the npdb does include a review and appeals process as a means of ensuring accuracy of the report.


    * the healthcare integrity and protection data bank was developed to combat fraud and abuse in health insurance and health care delivery. the hipdb database gathers information on final adverse actions taken with regard to: 1) any and all criminal action that is related to practice of one's profession; 2) health care fraud and abuse; 3) medicare and medicaid violations, sanctions and exclusions; and 4) state disciplinary action related to licensure. state boards of nursing are currently required to report final actions against a registered nurses license to the hipdb. as with the npdb, this database serves as an alert to government agencies and health plans that there may be a problem with a health care practitioner, provider organization or supplier.



    policy recommendations

    * protecting patients against potentially harmful actions by nurses, either intentional or unintentional, is a multilayered, multidimensional responsibility involving individual registered nurses and nurse managers and employers' human resources departments, as well as state and federal agencies.

    * with regard to national reporting, ana recommends that the reporting requirements for rns and other health professionals be the same as that for physicians and dentists (for whom reporting is already mandated). the reality is that employers must be held accountable when it comes to reporting information into these databanks and querying them prior to the hiring of nursing job applicants.

    * ana strongly recommends that any reported information be limited to final actions only. ana does not support the reporting of investigations that are still ongoing and in which no final action has been taken.

    * as with any new mandate, sufficient federal funding must be available to ensure the capacity of the databases to meet the additional burden that may result from this new requirement.

    * ana has long been a proponent of "whistleblower" laws that would prevent employers from taking retaliatory action against nurses through actions including suspension, demotion, harassment or discharge for reporting improper quality of patient care. such efforts may need to be broadened to protect registered nurses who report the unsafe practices of colleagues.

    * ana believes that regardless of which reporting or credentialing mechanisms are put into place - whether at the facility, state or national level - the principles of due process, dedicated to safeguarding the rights of the individual, and justice must be paramount.

    * ana has met with the staff of new jersey sens. jon corzine (d) and frank lautenberg (d), who have suggested they would sponsor federal legislation to address gaps in reporting of nurse information and will continue to monitor and shape initiatives at the federal level. ana also is monitoring the progress of proposed state legislation in new york and new jersey.

    ana contacts:
    cheryl peterson, senior policy fellow: 202-651-7089
    windy carson-smith, legal counsel: 202-651-7061
    erin mckeon, associate director, government affairs: 202-651-7098
    ana media contact: cindy price, 202-651-7038
    ^^^^^^^^^^^^^^^^^^^^^^

    a&e tv network

    show: cold case files

    tonight at 10 pm est

    will profile the cullen case

    "angel of death:killer nurse."




    the show is repeated thur the week.

    adios
    nurse betty
  6. by   Geeg
    Wonder if the improved ratio for liver donors has helped or hurt the donation cause. I think that the live liver lobe donors are taking a huge chance. I don't favor the procedure. I took care of a 17yr old girl who I believe was coerced into donating for her alcoholic mother. Felt sorry for her.
  7. by   NRSKarenRN
    from: nj state nurses association:
    http://www.njsna.org/ceo%20agenda/ceoagenda.htm

    february 3, 2004

    the duty to report

    the biggest surprise in the charles cullen case (the nj rn who confessed to killing as many as 40 patients in pennsylvania and nj over a 13 year span) was the revelation that acute care hospitals do not share any information about an rn when asked by another hiring facility. the outrage, of course, was that not even dangerous behavior was passed along. is this because the hiring is done by non-clinical people or do the hospitals really believe that rn's are just not important enough to investigate?

    there is no doubt that something in mr. cullen's misbehavior was noticed over the years by his fellow nurses, and, in fact, he was finally exposed by a combination of icu nurses and apn's and md's who figured him out. where do suspicions about our fellow clinicians go? njsna will be voting on a resolution outlining the rn's duty to report. the draft of that resolution is in this issue of the nj nurse. njsna will also be asking the nj legislature to authorize the board of nursing to create an alternative to discipline program which encourages earlier reporting and the hope of preventing patient harm.

    finally, we will support protection from liability for institutions who share information in good faith and protections for nursing faculty who in good faith fail or otherwise prevent an inappropriate student from pursuing a nursing career. we, the nurses, are the solution to this problem of scoundrels among us and given the correct tools we can keep our patients from harm.

    andrea w. aughenbaugh, rn, cs, cae
    chief executive officer

  8. by   penny0314
    don't hold your breath on hospitals reporting on the performance of nurses or any other employees. the legal liability of reporting a reference on an employee is enormous. few employers are in a position to so carefully vet references that personal opinion is excluded and 100% of the reference is objective. the minute you stray into subjective reporting, you run legal risks. apropos of the cullen case, i am not certain that reporting of "references" would have made a difference in this case. the nursing shortage is so acute, and reasons for dismissal so varied and often prejudiced, that mr. cullen probably would not have had a great deal of difficulty finding another position in a hospital, even had they known about the 5 dismissals--and there were 5 where he left in apparently good standing.
    Quote from nrskarenrn
    from: nj state nurses association:
    http://www.njsna.org/ceo%20agenda/ceoagenda.htm

    february 3, 2004

    the duty to report

    the biggest surprise in the charles cullen case (the nj rn who confessed to killing as many as 40 patients in pennsylvania and nj over a 13 year span) was the revelation that acute care hospitals do not share any information about an rn when asked by another hiring facility. the outrage, of course, was that not even dangerous behavior was passed along. is this because the hiring is done by non-clinical people or do the hospitals really believe that rn's are just not important enough to investigate?

    there is no doubt that something in mr. cullen's misbehavior was noticed over the years by his fellow nurses, and, in fact, he was finally exposed by a combination of icu nurses and apn's and md's who figured him out. where do suspicions about our fellow clinicians go? njsna will be voting on a resolution outlining the rn's duty to report. the draft of that resolution is in this issue of the nj nurse. njsna will also be asking the nj legislature to authorize the board of nursing to create an alternative to discipline program which encourages earlier reporting and the hope of preventing patient harm.

    finally, we will support protection from liability for institutions who share information in good faith and protections for nursing faculty who in good faith fail or otherwise prevent an inappropriate student from pursuing a nursing career. we, the nurses, are the solution to this problem of scoundrels among us and given the correct tools we can keep our patients from harm.

    andrea w. aughenbaugh, rn, cs, cae
    chief executive officer
  9. by   Havin' A Party!
    On my way to work now, so only skimmed the previous posts.

    Justed wanted to ask whether all other healthcare professionals are covered by the same requirements now being proposed for nurses? What the nurse at issue did could readily be done by colleagues in other disciplines within our general biz.

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