The Good Nurse and Swiss Cheese Model of Error

Have any of you read Charles Graeber’s The Good Nurse: A True Story of Medicine, Madness, and Murder?  If you did, what did you think?  Did you think that this is an example of a completely individual, idiosyncratic case?  Who did you blame?  The killer, Charles Cullen, who over a decade or so murdered maybe 300 patients (no one really knows how many) in hospitals in New Jersey and Pennsylvania?  Cullen was, of course, a total nutcase.  So who could blame you if you blamed him?  He was, after all, guilty.  But think again.  Were there other guilty parties, others who were witting accomplices to his crimes?  Were there dozens, maybe, even hundreds?.  And were they perhaps even more guilty than he was?

To me Graeber’s excellent and exceedingly creepy book — that by the way every patient safety advocate should read — is a perfect example of what I call at TSF (Total System Failure) and an almost textbook example of what James Reason calls the Swiss Cheese Model of Error.  According to Reason, no major error — and believe me this was an error of massive proportions — can happen due only to one individual acting solo.  To have a huge error occur, all the holes in a stack of Swiss Cheese have to line up perfectly so that the error (imagine it as a small pebble)can fall through.  In this case,  many hospitals and their leaders and staff knew that Cullen was killing people and either failed to act or actually impeded action that could have stopped him and saved lives.

Take, for example, Saint Barnabas Medical Center in Livingston, New Jersey where Cullen got his first job as an RN and began his killing spree.  Security officers at Saint Barnabas actually discovered that Cullen was killing patients by 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, the hospital shut down any investigation and just fired him, sending him on to the next hospital and the next, and the next.  Like the Catholic Church and pedophile priests, these hospitals where Cullen worked were more concerned about bad press and lawsuits than saving patients.  I don’t want to sound to harsh (although I’m not sure you can sound too harsh in this case) but I actually blame hospital executives more than Cullen.  He was, after all, a lunatic.  They were supposed to be sane.  But the men and women who didn’t alert the police after Cullen killed his first two victims, it seems to me, have the blood of 298 more patients on their consciences.

I don’t think these people are bad people.  They’re not like Cullen, psychopaths who need to kill.  I think their inaction represents yet another example of what Hannah Arendt called “the banality of evil.”  This was a term she coined to describe Adolph Eichman, the officious bureaucrat who helped to execute Hitler’s Final Solution.  Although there is debate about Eichman’s actual enthusiasm for his job, I think Arendt’s term is apt and describes a lot of semi-neutral people who do nothing in the face of the unfolding of potentially catastrophic events that they could perhaps stop.

What Arendt describes as the banality of evil was what political philosopher Edmund Burke wrote in the 18th century when he said,” All that is necessary for the triumph of evil is that good men do nothing.”  How much nothing is being done today in healthcare by good men and good women?  Does that contribute to our failure to reduce the toll of harm being done to patients in our healthcare system on a daily basis?

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