GOALS AND ISSUES IN MANDATORY REPORTING

This chapter focuses on illegal and irresponsible activities that fall outside the boundaries of professional practice. Such illegal actions require reporting the incident to the State Board of Nursing, and the profession is responsible for “policing” such activities, preventing them, and ensuring a due course of legal action when these professional practice boundaries of good practice are crossed. This is where Marx (2001) cautionary notes on a “blame-free” culture are particularly well taken and appropriate. According to Marx (2001), “blame free” can never mean “responsibility free,” and some acts fall outside ethical comportment altogether or are egregious and blameworthy. It is one thing to govern and engage in self-improving practices within the bounds of commitment of the practitioners to uphold the standards and notions of good internal to the practice (MacIntyre, 1984), and quite another when practitioners willfully violate the notions of good practice. Some people, within every discipline for whatever reasons, do not choose to uphold the standards of their practice and fall outside ethical practice. Papadkkis (2008), at the University of California San Francisco, found that medical students who had problems with “professional behavior issues” were more likely to be reported to the state board of medicine. This is a cautionary tale for nurse educators as well. Sometimes people may intellectually assent to the standards and boundaries of good practice but not accurately discern in practical situations where these standards are salient and relevant. Others blatantly choose to ignore or violate the professional standards, and therefore do not engage in the essential commitments and formative skills related to good practice. Sometimes, however, extenuating circumstances call for choosing to repair a crisis situation in the only way possible under the circumstances. The patient falling off the operating table had already experienced a serious practice breakdown, and there was no safer choice than to continue the operation under compromised conditions and offer the patient full disclosure of the error. Sometimes in an emergency a contaminated piece of emergency equipment may be used, and when time is essential for saving the patient’s life, the safer choice is to use the contaminated instrument to establish the airway or inject an emergency resuscitative medication. Repair of a breakdown situation is the best that can be achieved. Full disclosure to the patient is warranted, and redesign strategies to prevent such future problems are in order. But here we turn to criminal and egregious acts that fall outside of professional practice.

Consider the situation where one nurse observes another nurse reusing a needle. The best practice is to confront the nurse first and inform her that an incident report will be filed with the nursing supervisor. The nurse supervisor, after gathering relevant data about the incident, and consulting with the nurse, will then judge whether it is an isolated and unintended mistake or a repeated pattern of substandard practice. If it is a repeated pattern of substandard practice, the supervisor should report it to the State Board of Nursing. Sometimes nurses over-step the ethical and legal parameters of their practice license. For example, the nurse who administers morphine to a non-responsive, terminally ill patient violates the Nurse Practice Act, and must be reported to the supervisor, and the State Board of Nursing. Accurate documentation of the erroneous medication incident must be completed by the nurse who administered the narcotic. It is the fiduciary and legal responsibility of the nurse to report and attempt to correct practice breakdown of any health care team member including herself.

To address this dilemma, 49 of 59 boards of nursing in the United States have enacted some form of regulatory mandates that require the reporting of certain negative events to their state boards of nursing. The goal of mandatory reporting is to ensure that unsafe practice behaviors are addressed appropriately and in a timely manner. Examples of behaviors in mandatory reporting regulations typically include the following:

Unfortunately, the definitions and processes surrounding mandatory reporting vary widely across the country causing confusion and misinterpretation. For example, some states require notification for specific behaviors while others identify general categories of behaviors related to practice breakdown. Some states require that only the “final disciplinary action” be reported concerning any health care professional or voluntary resignation against whom any complaints or reports may have led to disciplinary action. Single incidents of practice breakdown must be reported in some states, while other states require that patterns of practice breakdown be reported.

There are advantages and disadvantages to mandatory reporting. The advantage is that negative behaviors are identified and referred to a sanctioned group of professionals familiar with the nurse practice act. One disadvantage is that mandatory reporting often shifts the accountability for the management of practice breakdown from the organization to the regulatory board, thus eliminating the opportunity for early remediation and retraining without the stigma of a state board’s involvement. Although the goal of mandatory reporting is to protect the public and ensure prompt resolution of the breakdown, adversarial relationships between nurses, organizations, and boards of nursing and the public may make early detection, local reporting, remediation, and system redesign slower and more contested.

The work of the Practice Breakdown Advisory Panel has been to reconceptualize the nature of error and focus on the creation of a just culture to manage practice breakdown. In a just culture, missteps are viewed as critical learning opportunities for patient safety. The intent is to avoid the tendency to blame individuals for patient safety issues when, in fact, much more may be involved.

Despite mandatory reporting laws, glaring gaps in the system persist. This chapter examines a well-publicized case involving Mr. Charles Cullen, a nurse who is identified by name in the chapter, as his actions received national attention and stories about him appeared in newspapers and other publication outlets in the country. In this regard, the case description is an exception to this book’s policy of not revealing a nurse’s identity.

In this well-publicized case, the nurse, with seemingly malevolent intent, appeared to have “slipped through the cracks,” traveled from one short-term job to another, and escaped detection for many years. The Cullen case is a dramatic example of the failures and opportunities for improvement in the current health care system.

HISTORICAL CASE STUDY #1: The Charles Cullen Case

Mr. Cullen dropped out of high school and enlisted in the Navy soon after his mother was killed in an automobile accident. He first attempted suicide while enlisted, and his behavior reportedly led to a discharge from the Navy in 1984. Mr. Cullen returned to New Jersey and enrolled in a hospital-based nursing program. After graduation, he secured his first nursing position at hospital #1 where he worked first as an employee in its burn unit and subsequently as a “pool” nurse. It was during this period of time that he married and started a family.

Mr. Cullen was not fired from hospital #1 but was forced out when he was given a decreasing number of work assignments for undisclosed reasons. His next position was at hospital #2, in 1992, where he was assigned to work the night shift in the critical care unit. During that time period, he divorced and became infatuated with a female co-worker.

On March 23, 1993, he was arrested for trespassing when he broke into the co-worker’s home. He pleaded guilty to downgraded charges and was sentenced to 1 year probation. Also during this period, he attempted suicide for a second time, took 2 months leave from work, and entered psychiatric treatment at a state psychiatric hospital.

Mr. Cullen returned to work as a nurse at hospital #2. During this time, he was questioned about deaths that occurred when he was on duty. On August 30, 1993, Mr. Cullen was caring for Ms. A, a 91-year-old woman in the critical care unit, who was recovering from breast cancer surgery and was showing signs of improvement. On one of the days in the unit, she received a nonprescribed injection of digoxin and died the next day from heart failure. Ms. A’s son accused Mr. Cullen of murder. Mr. Cullen underwent and passed a lie detector test, and the accusations ended. Shortly thereafter, Mr. Cullen voluntarily left his job at hospital #2.

Next, Mr. Cullen secured a position at hospital #3 where he became involved in a series of policy infractions. Reportedly he was written up twice: once for tampering with the oxygen settings on the ventilators and once for not following a doctor’s orders to discontinue medication. He was fired in August 1997 for “poor performance.” After leaving hospital #3, Mr. Cullen crossed over the Delaware River into Pennsylvania and sought work at hospital #4.

Mr. Cullen was described as a loner, angry, and weird by co-workers. He had credit card debts of $40,000 and declared bankruptcy by the time he left hospital #3.

On May 28, 1998, at hospital #4, he was caring for the roommate of Ms. B who received an injection of insulin that seemed to have caused her death. Several nurses were questioned about the sudden death of Ms. B, but nothing conclusive could be determined.

In October 1998, Mr. Cullen was terminated for administering medication at unscheduled times. These infractions were not reported to the board of nursing because, in the view of hospital #4, it did not appear to be the kind of conduct that required reporting.

After leaving his job at hospital #4, Mr. Cullen went to work at hospital #5, which was also located in Pennsylvania. On December 31, 1998, Mr. C received a lethal dose of digoxin on the night Mr. Cullen was caring for him. Mr. Cullen left employment at hospital #5 shortly thereafter and subsequently secured work at hospital #6. He made a third attempt at suicide and was again hospitalized for psychiatric treatment.

Mr. Cullen voluntarily resigned his job at hospital #6 and took a position at hospital #7 in June 2000. He worked in the critical care unit on the night shift. Shortly thereafter, he was accused of leaving unopened boxes of medication containing vials of nitroprusside and procainamide in the sharps container. The boxes were removed, but the very next day there were additional unopened unused vials found in the sharps container. A co-worker reported him to the hospital administrator. When questioned, Mr. Cullen was unable to explain why he was storing medication that was not seen as addictive and had little street value. The hospital administrator terminated Mr. Cullen and reported him to the Pennsylvania Board of Nursing, which took no formal action against him.

His next place of employment was at hospital #8 in Pennsylvania. He was fired after 16 days of employment. The documented reason was because he was unable to get along with his co-workers.

Mr. Cullen then crossed back over the river into New Jersey and took a job at hospital #9. The hospital’s check of his credentials and past employment history revealed that he had valid nursing licenses in New Jersey and Pennsylvania. No derogatory information was relayed by any past employer to hospital #9 since employment policies at most of these facilities allowed only for the confirmation of his dates of employment. Mr. Cullen’s past employment history was not revealed.

While at hospital #9, Mr. Cullen was assigned to work on the night shift in the critical care unit. In June 2003 he cared for Mr. D, a patient diagnosed with cancer. Mr. D suffered sudden heart failure after being injected with a nonprescribed dose of digoxin. Prior to this incident, two other patients had suffered life-threatening decreases in blood sugar caused by insulin overdoses. The hospital did not report the incidents to the police or to the New Jersey Board of Nursing at that time, but they did consult with a doctor from the New Jersey Poison Information and Education System.

Mr. Cullen continued to work at hospital #9. On July 27, 2003, Mr. E, who was in the ICU at the hospital, received a nonprescribed dose of digoxin and died of heart failure the next morning. The lab results showed toxic levels of digoxin in the patient’s system.

Meanwhile, the hospital received feedback from the expert at the New Jersey Poison Information and Education System. He informed hospital authorities that he intended to report the matter to the New Jersey Department of Health and Senior Services. Eight days later, Mr. F, another patient, suffered a precipitous drop in his blood sugar and died. The hospital administrator immediately notified the county prosecutor’s office and that office launched an investigation.

The prosecutor’s office reviewed pertinent medical records and on December 8, 2003, alerted the New Jersey Board of Nursing of an impending arrest. On December 12, 2003, Mr. Cullen was arrested and charged with one count of murder and one count of attempted murder.* On request made by the New Jersey Board of Nursing that very day, Mr. Cullen signed an interim order of voluntary surrender pending the completion of the criminal case. On April 29, 2004, after Mr. Cullen pleaded guilty to multiple counts of murder and attempted murder in County Superior Court, he signed a consent order with the New Jersey Board of Nursing agreeing to permanently surrender his license to be deemed a license revocation. His license was also revoked in Pennsylvania.

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