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At the end of the The Good Nurse, a Netflix film based on the 2013 book by journalist Charles Graeber, we learn that registered nurse Charles Cullen, may have killed as many as 400 patients in the nine hospitals he worked in in Pennsylvania and New Jersey during his 16-year career. This makes him one of the most prolific serial killers US history.

Both the book and movie reveal how Cullen operated in plain sight as he moved freely between hospitals before he was convicted and imprisoned for killing 29 confirmed victims. The film, by Danish director Tobias Lindhold, begins when Cullen, played by the British actor Eddie Redmayne,  comes to work at his ninth and final workplace. He meets Amy Loughgren, played by Jessica Chastain, who is the good nurse who worked with police to bring Cullen to justice.

When Cullen arrives on her short staffed ICU, Loughgren, a single mother of two, who has concealed a life-threatening heart problem from her employer, is struggling on the night shift. She is relieved when told she’ll be getting help from a “really good nurse,” who’s just joined the hospital staff. She and Cullen become friends when he discovers her health problems and offers to help her with her patient load. When a patient who seemed to be on the road to recovery suddenly dies, she initially doesn’t suspect that anything is amiss.

Two police officers arrive at the institution when it’s forced to report the suspicious death. The detectives become increasingly concerned when the hospital’s risk manager—who is also a nurse—refuses to give them the full report on its own internal investigation of the suspicious death. They become even more certain that “something is not right,” when the hospital board and their high-priced lawyer continue to stonewall their investigation. Their frustration mounts when the DA in charge of the case, who is politically connected to the hospital administration, won’t support a thorough investigation into the sudden deaths of even more ICU patients.

Enter Loughgren, the real good nurse in the movie. She is called in to speak with the police and helps them decipher the meaning of the medical notes in the patients’ charts. The first patient who died wasn’t diabetic, but had insulin in her blood. As other patients die, Loughgren finds that some who weren’t prescribed digoxin for heart problems also had that drug in their system. With police encouragement, Loughgren does her own detecting and discovers that Cullen was injecting saline bags with the two drugs and was also manipulating a flaw in the hospital’s computerized medication dispensing system, so that he could acquire these drugs without the computer registering their use.

With the help of Loughren, Cullen is finally brought to justice, but as the screen notes explain, no one in any hospital in which Cullen worked was ever prosecuted for failing to stop his murderous activities.

This is the real moral of the story—one which is told in even more devastating detail in Graeber’s book, which should be required reading for anyone working in healthcare and concerned about patient safety.

Cullen was, of course, deeply disturbed. So it’s tempting to blame him and him alone for killing hundreds of patients. As the famous British organizational psychologist James Reason has often stated, human beings find it far more emotionally satisfying to blame an individual for a problem than it is target the systems which provided a fertile environment for their “forgetfulness, inattention, or moral weakness.”

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In the Cullen case, Graeber explains, the blueprint eight other hospitals were to follow was established at Saint Barnabas Medical Center in Livingston, New Jersey, where Cullen got his first job as an RN and began killing patients. Security officers at Saint Barnabas actually discovered that Cullen was injecting IV saline solution with Insulin. Cullen was so eager to be caught and stopped that he didn’t even use gloves when injecting the bags and his fingerprints were all over them. He was surprised no one caught him. 

But when security officers went to the police, its chief, about to retire and hoping for a job at the institution, shut down any investigation. The hospital fired Cullen and wrote a neutral recommendation that allowed him to move on to another hospital. The seven other hospitals he worked at followed that blueprint faithfully. Like the Catholic Church moving its pedophile priests from parish to parish, these hospitals were more concerned about bad press and lawsuits than saving patients.

Administrators, hospital boards and CEOs, and risk managers weren’t the only part of this deeply flawed system. So too were RNs, MDs and other staff. When RNs and MDs graduate from their medical and nursing school, they all repeat the words of either the Hippocratic Oath, or the Florence Nightingale Pledge, which is to protect the patient and “first do no harm.” In all of the hospitals that employed Charles Cullen, dozens, perhaps even hundreds, of physicians, and nurses knew or suspected what was going on, but were too afraid of risking their jobs to turn him in. 

As Graeber writes, many breathed a sigh of relief when the problem disappeared because their particular hospital let Cullen go. No one alerted the authorities when he moved on. This total system failure was only interrupted when one good nurse—who was no less frightened about losing her job than hundreds of other healthcare professionals—took her oath seriously and helped the police.

But one good nurse isn’t enough to protect patients from the real threats they face in America’s hospitals. The real threats patients face do not come in the form of killer nurses, or physicians—and the silence of colleagues or co-workers who stand by the sidelines and say nothing. The real threats patients face are the preventable medical errors and injuries that, every year, kill over 250,000 patients and leave another 1.5 facing serious medical problems. 

As studies have documented, most of these errors and injuries are the result of failures of communication rather than incompetence or lack of knowledge. Someone knew that a patient was getting the wrong dose of a drug—by accident rather than on purpose—or that the wrong limb or organ was being operated on and said nothing or not enough.

To move from a culture of fear and silence to one of genuine advocacy and assertion will require more than individual courage on the part of a single nurse or doctor. It will require hospitals and state and federal governments to do what the airline industry did in the 1980’s (an effort that continues today), which is spend millions to train staff to speak up and risk managers to actually identify and prevent, rather than conceal risks to both passengers and staff. 

As a result of these efforts crashes have become rare events and thousands of lives have been saved. If hospitals finally act to take safety seriously, they too will save millions of lives and maybe also unmask the odd killer nurse or doctor not at the end of their murderous career but at the beginning.