Want to detect dangerous staff? Use background checks, monitoring
Want to detect dangerous staff? Use background checks, monitoring
Check any suspicious pattern of deaths, look for common staffer
The story hits the news every once in a while, but it always seems like such an extreme case: A hospital staffer confesses to killing multiple patients over time, usually with fatal injections and often under the pretense of a "mercy killing."
But is there anything a risk manager can do to prevent such a tragedy, or is this such an extreme scenario that it's not worth the effort? Risk managers who have been through this problem say it most certainly is worth your time and effort to screen out these potential killers and spot their crimes as soon as possible.
"If you think you're immune from this kind of problem, you're kidding yourself," says Peggy Nakamura, RN, MBA, JD, DFASHRM, CPHRM, assistant vice president, chief risk officer, and associate counsel at Adventist Health in Roseville, CA. She also is a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago.
Nakamura experienced such a situation in her own organization and she says it opened her eyes to how much risk managers must be proactive in preventing serial killers from harming their patients. In 1998, Efren Saldivar, a 28-year-old respiratory therapist at Glendale Adventist Medical Center in Los Angeles, confessed to killing 40-50 patients over the previous decade, mostly with the drugs Pavulon and succinylcholine chloride. He was fired and now is serving life in prison.
Dozens of killings possible
Nakamura presented her advice recently at the recent annual ASHRM meeting, along with Kenneth N. Rashbaum, JD, an attorney with Sedgwick Detert in New York City. He was involved with investigating the case of Charles Cullen, a nurse who pleaded guilty in 2004 to the murders of 13 patients at Somerset (NJ) Medical Center. In return for a plea agreement that would spare him the death penalty, Cullen agreed to cooperate with prosecutors investigating patient deaths in five additional New Jersey counties where he had worked as a nurse.
He eventually confessed to using various injections to commit murders at five additional hospitals before going to work at Somerset, Rashbaum reports. Cullen has confessed to about 30 murders at the different hospitals, with the exact number depending on which law enforcement agency is counting. When the Cullen story broke, it revealed the problem that risk managers can face when trying to screen out dangerous employees. Most health care employers will not provide anything more than the bare minimum of information about a past employee — what Rashbaum calls the "name, rank, and serial number" response.
In defending itself against claims that the hospital's negligence allowed Cullen to kill with impunity, Somerset Medical Center pointed out that Cullen had worked at nine other health care facilities over 16 years and had a long history of questionable behavior. But none of those previous employers alerted other health care providers when asked for a reference.
"The hospital said they could have been sued for saying anything negative about the former employee, and they were right," Rashbaum says. "The name, rank, and serial number response is policy at most hospitals because they want to avoid a negligent misrepresentation lawsuit."
The health care industry and state legislatures need to provide protection against such lawsuits and encourage employers to provide full information about past employees, especially any clinician who has displayed dangerous behavior, Rashbaum and Nakamura say. But until that happens, the onus is on risk managers to protect the organization from these killers.
Background checks are first defense
Rashbaum emphasizes that stopping these killers requires a multidisciplinary team. The risk manager may have to take the lead, but human resources and legal counsel must be involved.
Nakamura says the first hurdle is the naturally benevolent mindset found in most health care professionals. Health care providers tend to be trusting, she says, but some degree of objective skepticism is necessary. "In our incident, it was impossible to believe, but the facts were presented to us," she says. "We are trusting individuals, and it is hard for us to believe there are criminal minds in health care."
To counter that tendency, Nakamura says you must be skeptical when viewing any reports of suspicious behavior in an employee, especially any that suggest a pattern. Never assume that the incident was just a mistake or misunderstanding, or that the person simply wasn't trained well enough.
The best way to prevent a killer from preying on your patients is to keep him or her out of the facility altogether, say Nakamura and Rashbaum. They advise conducting thorough background checks on all employees, looking for any hint that the person has been involved in criminal behavior before or might have been dismissed from other health care facilities. They offer this advice on background checks:
- Know your own state requirements for background checks and those of adjoining states if you draw employees from over state lines.
- Always verify the applicant's identity, and consider using fingerprinting as the most accurate means of verification. "It's amazing how many applicants have falsified their identity," Nakamura says. "Start with simply verifying that they are who they say they are."
- If the applicant was discharged from the military, ask for a copy of Form DD-214. In addition to verifying the discharge status, the DD-214 may include interesting information about performance, disciplinary action, and psychiatric testing.
- Request a copy of the applicant's last performance review from the previous employer.
"Be suspicious if they don't have it or even the previous one," Nakamura says. "I've always found that people keep copies of their performance reviews, especially the good ones. Watch how they respond to this request."
Rashbaum and Nakamura point out that you must be careful when conducting background checks. If you use conviction records, for instance, your organization should have a specific policy that outlines how you will react to the nature and gravity of the offense, plus the time since the offense. Will you rule out someone who was convicted of a nonviolent misdemeanor 20 years ago?
If you consider arrests in addition to actual convictions, the bar has to be set higher. Nakamura says the conduct leading to the arrest should be related to employment, and you should look to your own state law for further restrictions. If you use an outside agency to conduct background checks, review the contract carefully to see exactly what information the agency will pursue. In particular, you should ask if the agency will be searching in other states, because killers in health care often move from one state to another in an effort to hide their history.
Nakamura also advises risk managers to implement revised data collection procedures in an effort to thwart (or at least detect) any criminals who slip through your screening process. She offers these tips:
- Conduct routine toxicology screens immediately post-cardiac arrest for all patients, without waiting until there is reason to suspect foul play.
- Obtain monthly code and death statistics by unit, shift, and total hospital. Compare units to each other and themselves.
- Require strict pharmacy and unit accounting of all doses of medication. After the incident at Nakamura's facility, the hospital had to change pharmacy practices to ensure that Pavulon was monitored closely.
- Incorporate data from those policies into any root-cause analysis after a suspicious or unexpected death.
Keep close eye on temporary staff
Temporary staff pose a special risk, Nakamura says, because they are unknown to others on the unit, and serial killers often move quickly from one facility to another. Risk managers should require enhanced monitoring of temporary staff and in particular, they always should be closely supervised by management and should work alongside regular staff, Nakamura says.
"Avoid having all temporary staff on one unit," she says. "That is really dangerous, especially on a critical care unit."
Managers should closely review temporary staff members' performance and require adherence to all organizational policies. It is never acceptable to overlook poor performance or shortcuts just because the staffer is temporary. Nakamura also advises assigning a senior staff member to "buddy" with the temporary staffer and report to department management.
"Anybody who is new should be watched closely, and temporary staff always represent a risk," Nakamura says. "They may think that they will be long gone by the time anyone suspects anything."
Sources
For more information on screening for employees with criminal intent, contact:
- Peggy Nakamura, Assistant Vice President, Adventist Health System, 111 N. Orlando Ave., Winter Park, FL 32789. Telephone: (407) 647-4400.
- Kenneth N. Rashbaum, Sedgwick, Detert, Moran & Arnold, 125 Broad St., 39th Floor, New York, NY 10004-2400. Telephone: (212) 422-0925. E-mail: [email protected].
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