Charles Cullen: Healthcare Serial Killer

In June 2005, several newspapers published the results of a long meeting with Cullen in which he offered advice for healthcare institutions in how to make it more difficult for people like him to do what he did. In short, he said, there should be protocols for accountability for staff and for drug-handling procedures. Among them would be installing surveillance cameras, the use of swipe cards and bar codes, and a daily count of lethal medications. He also said there should be a national database for updating employment history of healthcare workers. Institutions should pass information along to one another, Cullen advised, and hospitals should pay attention to the mental health of their employees. Poor performance such as his should be reported to the state board of nursing. The best deterrent, one of his listeners interpreted him to mean, is the certainty of detection.

New Jersey Governor
James McGreevey

In his various responses, Cullen's personality is clear: He blames others. He holds hospital administrators responsible for not stopping him or reporting him. He blames the way hospitals operate, which is to say, he exploited the trust factor present in places where employees have patient wellbeing as a goal: it was their fault, not his, for being so gullible.

One of his MOs was to get medications by opening patients' drawers or closets, because no one tracked the drugs. When electronic drug tracking was put into place, he simply learned how to manipulate computer records. He left "tracks," but no one noticed until he made a mistake. There was no system in place for making people who got the drugs accountable for them. In another place, he recalled, a storage room for drugs was never locked and it was easy for him to pilfer them. He claimed he threw away thousands of dollars worth of pharmaceuticals, but no one seemed to notice.

Officials in both states were already busy getting policies and procedures into place. State regulators in NJ strengthened nursing standards, with new rules and harsher penalties. They also introduced the Safe Health Care Reporting Act, which would expand the current National Practitioner Data Bank to include all licensed healthcare workers, not just physicians. And legislation was considered in both PA and NJ to protect hospitals from lawsuits should they have reason to offer a negative evaluation to a former employee's new employer. In April 2004, writes Alexander, New Jersey Governor James McGreevey signed a law that requires all healthcare facilities in the state to document and report serious medical errors, and some PA hospitals will tell prospective employees before hiring that they will pass along whatever negative information they have.