Editor's note: This article is the first installment in a two-part series by Emily Friedman on the topic of rogue practitioners. Her second installment will appear in H&HN Daily on Feb. 4, 2014.

In 1893, it must have seemed that half the population of the United States had descended on Chicago to attend or work at the World's Fair: Columbian Exposition. Waiting for some of them was Herman Mudgett, a physician who had taken the name of Henry Howard Holmes. He had set up shop in a drugstore that he had promised to purchase but never paid for; the owner, a widow, had mysteriously disappeared. He later bought a lot across the street and constructed what became known as the "Murder Castle," where he killed many young women, most of them in his employ, often collecting life insurance on them. The building was equipped with rooms where his victims could be asphyxiated or killed in other ways, as well as chutes down which the bodies were sent for disposal.

Holmes later left Chicago for Texas, St. Louis, Toronto and other locations, killing people all along the way. He was finally arrested in Boston in 1894, tried, convicted and hanged in 1896. His death toll is estimated to have been somewhere between 20 and 200 people, most of them women. His story is told in Erik Larson's excellent and very disturbing book The Devil in the White City (Crown Publishers, 2003).

Holmes was probably the first recorded American physician serial killer, but he likely was preceded by others of whom we are unaware. There is also an unhappy history of killer nurses, one of the earliest being Honora Kelley (1857–1938), who took the name Jane Toppan, the surname being that of a family to which she was bound as an indentured servant.

She started her nursing education at Cambridge (Mass.) Hospital in 1885, where she experimented on her patients with large doses of narcotics. She then moved on to Massachusetts General Hospital, Boston, where she apparently murdered several patients before being fired. She went back to the Cambridge hospital, but was let go for overprescribing opiates. In 1895, she fatally poisoned her landlords, and moved on to murder several other people she knew. She was arrested in 1901 and subsequently confessed to killing at least 31 people. She was found to be mentally unfit for trial and spent the rest of her life in a psychiatric facility. She apparently once said that she wanted to kill more helpless people than anyone "who had ever lived."

Yeah, yeah, you say, and Jack the Ripper was a bad guy, too, but all this was a long time ago. That couldn't happen these days.

Couldn't it?

More Recent Cases

Michael Swango was a physician who displayed enormous intellectual capacity, but who, as a medical student at Southern Illinois University in the early 1980s, seemed to have an unusual number of patients who coded, at least five of whom died. As chronicled in James B. Stewart's superb but deeply troubling book, Blind Eye (Simon & Schuster, 1999), Swango was able to get an internship at The Ohio State University Medical Center in 1983, despite a profoundly negative report from Southern Illinois. At the OSU hospital, nurses noticed that patients in Swango's care had a habit of dying mysteriously. One nurse reported this, but her concerns were dismissed. Leaders at OSU eventually conceded that the police should have been called in. Swango was not offered a residency once his internship ended.

It got worse. Swango poisoned his coworkers (nonfatally) while working as an emergency medical technician in Quincy, Ill., was convicted of aggravated battery and was imprisoned in 1985. He served four years. Once he was released, he changed his name and got a job as a physician in Sioux Falls, S.D., using forged documents. His new career foundered when he sought to join the American Medical Association, which conducted some research and unearthed his conviction at about the same time a television show aired a segment about him. He was fired.

Swango went on to a residency at the State University of New York (SUNY)–Stony Brook medical school, where he worked at a Veterans Administration hospital — and his patients started dying in unlikely numbers.

After his ex-wife committed suicide and arsenic unrelated to her death was found in her system postmortem, her mother began notifying people about Swango's highly suspicious professional history. He was fired, and the dean at SUNY–Stony Brook, Jordan Cohen, was forced to resign. Before he left, Cohen undertook to warn every medical school and teaching hospital in the country about Swango.

Finding that pickings had dried up in the United States, Swango moved on to Zimbabwe, where an undetermined number of his patients died, and was on his way to Saudi Arabia when he finally was arrested in 1997. The original charge was fraud; he received 3.5 years in prison. But authorities in both the United States and Zimbabwe were investigating him and, in 2000, he was indicted on multiple counts of murder in this country. He was convicted and is serving three consecutive life terms. He is suspected of having killed between 35 and 60 people but, because he worked in so many places, the total number of his victims likely will never be known.

In his book, Stewart emphasizes that Swango could have been stopped at many points along the way if the hospital officials involved had listened to the suspicions of nurses, or if his prospective employers had been informed about the poisoning of his paramedic coworkers, or if someone had done something in terms of investigating his history before giving him access to patients.

The Swango story is instructive because it highlights one of the flaws in our health care system's efforts to keep monsters like him from plying their chosen trade in our hospitals: Often, health care organizations themselves have just passed these people on to the next provider, with no more information than dates of employment and perhaps a vague assessment of competence.

Registered nurse Orville Lynn Majors, on the other hand, did not move around; he killed all of his victims in one facility, Vermillion County (Ind.) Hospital, between 1993 and 1995, probably by injecting them with potassium chloride. He is suspected of having murdered more than 100 elderly patients.

His downfall came as a result of his odd behavior, derogatory comments about older people, and the fact that the hospital's mortality rate soared whenever he was on duty. Although other nurses were suspicious of him, at least some of them later said that they did not report their concerns because they were afraid of lawsuits or of losing their jobs. Others said that they did report the situation to their supervisors. In any case, his predations finally came to the attention of state authorities. He was arrested in 1997, tried and convicted of six killings. He is doing 360 years in a state prison.

Swango's and Majors' murder sprees ended in 1997, and they were, admittedly, outliers. Surely we have tightened things up since then, especially in light of Stewart's damning chronicle of a system that looked the other way despite mounting evidence of a serial poisoner moving from state to state, preying on patients.

But have we?

The Beast Goes On

The Swango and Majors cases were very high profile and are familiar to many people in and out of health care. But they were far from the only ones. Nurse Robert Diaz murdered 12 or more patients in several hospitals in California in 1981; he was convicted and died in prison while awaiting execution. Nurse Genene Jones was convicted in 1985 of killing as many as 46 infants and children in a hospital and a clinic in Texas; she injected them with overdoses of a variety of drugs. She is currently in prison but could be released soon. Terri Rachals, also a nurse, was convicted in 1986 of killing six patients and served 17 years in prison prior to being released in 2003. Nurse Kimberly Saenz killed several dialysis patients in 2008 by injecting them with bleach; she was convicted in 2012 and is doing life.

There are too many others. Kristen Gilbert. Donald Harvey. And Charles Cullen, a nurse who confessed to killing 29 patients but who may have dispatched as many as 400 people. He is serving multiple life terms. Cullen was another migratory murderer whose victims were patients in hospitals in New Jersey and Pennsylvania. He told authorities that he began killing in 1988 and kept at it until 2003, when the hospital where he was working notified state authorities that his record was suspicious; the hospital was later condemned for not acting sooner. Charles Graeber chronicles the case in his book The Good Nurse, published earlier this year by Hachette Book Group.

Cullen's case stands out for several reasons. For one thing, he is very intelligent and technologically skilled, and was able to manipulate computerized hospital drug-order tracking systems so that his numerous inappropriate orders of pharmaceuticals were not easily detected. He was smart enough not to use narcotics, but rather overdoses of commonly used drugs that are usually not lethal, such as insulin and digoxin. Also, he managed to find employment, and kill patients, in nine different hospitals before he was caught. Perhaps most important, he was stopped because another nurse, Amy Loughren, who was a good friend of Cullen's, became suspicious about his drug ordering patterns. She obtained printed records of his orders, scrutinized them, and took the evidence to police and prosecutors.

Interviewed by "60 Minutes" earlier this year, Cullen scoffed at the hospitals whose lax enforcement of policies allowed him to keep going, saying they should have detected and stopped him long before Loughren did.

And Even Now …

The two latest cases to come to my attention — and that spurred me to write this article — were those of Anthony Garcia, M.D., and David Kwiatkowski, a radiology technician.

Garcia, despite negative reports about him during his medical education, obtained his first residency at Creighton University Medical School in Omaha, Neb., in 2000. He was dismissed a year later for unprofessional conduct, an action that was approved by, among others, physicians Roger Brumback and William Hunter.

He subsequently — like so many others of his kind — had a series of short-lived positions in various places, including Chicago and Louisiana. He lost his residency in Louisiana in 2008 when it was found that he had concealed the termination of his Creighton position on his application.

Apparently convinced that the physicians at Creighton who had rejected him were ruining his life, Garcia returned to Omaha and allegedly murdered Hunter's son and housekeeper in March 2008. The crime went unsolved for five years while Garcia sought employment as a physician in several locales. Earlier this year, Brumback and his wife were murdered in their Omaha home. Similarities between these deaths and the Hunter killings led authorities to suspect Garcia, who was arrested in July and is now awaiting trial in Nebraska on four counts of first-degree murder.
Which brings us to David Kwiatkowski, an itinerant health care tech who had a little problem: He was addicted to fentanyl. His modus operandi, beginning in2002,was to steal syringes of powerful painkillers and replace them with syringes that he had already used and refilled with saline.

David Kwiatkowski was infected with hepatitis C.

Over the next eight years, he worked in 19 different hospitals in several states, leaving behind a trail of infected patients — and a mountain of evidence. He was fired twice for stealing drugs. He was arrested for driving under the influence. Co-workers noticed obvious signs of drug abuse. Yet, he was always able to obtain employment in the latter part of his infection spree through temporary staffing agencies, which allegedly vetted his credentials as well as his work history.

He was finally stopped in 2012 at Exeter (N.H.) Hospital, where several patients in the cardiac cath lab where he was employed were found to have a specific strain of hepatitis C. Kwiatkowski was the only employee who had the same strain.

As of this writing, he has pled guilty to a variety of counts and will serve between 30 and 40 years in prison when he is sentenced this month. At least 8,000 patients across the country whom he may have exposed have been advised to get tested for hepatitis C. So far, one patient likely infected by Kwiatskowski has died.

Nineteen hospitals? He had been observed stealing syringes filled with painkillers. He was found in one hospital bathroom in a stupor with a fentanyl syringe floating in the toilet next to him. He had been seen at work, foaming at the mouth and acting out of control, and a friend found used needles in his laundry. Yet his resumé mentioned none of this, the staffing agencies continued to place him, and patients continued to contract the strain of hepatitis C that he carried.

This isn't ancient history from the 1893 World's Fair. This was yesterday. Garcia has not yet been tried, and Kwiatkowski has yet to be sentenced.

How can these people continue to do this to our patients?

Very Bad Needles in a Very Large Haystack

Hindsight, of course, affords all of us perfect vision. These people stand out like sore thumbs once we know about them — certainly someone should have noticed this; someone should have reported that.

But, it is important to remember that health care's serial killers are extreme rarities. There are 3.5 million nurses in the United States, and 878,194 physicians have active licenses. The overwhelming majority are committed, skilled healers who would never knowingly harm a patient.

But that does not change the fact that there are monsters in our midst.

So, why can't we identify and stop them?

Denial. No one in health care finds the thought of clinician serial murderers easy to swallow. The concept of a "killer nurse," especially, seems to be a contradiction in terms. Health care professionals do not exactly constitute a club, but there is a sense of fraternity or sorority, the notion of something shared. Members of our group would never do anything like that. This attitude can be fatal.

Innocence and ignorance. Most health care professionals do not receive adequate training, if any at all, in how to spot a psychopathic colleague. Yes, there is a lot of information about impaired practitioners and how to identify them and get them help, but forensic documentation of serial killers isn't usually included in the curriculum. It just isn't something that one would normally be watching for, and the evidence is often subtle, at least in the beginning.

Fear. In many of the cases I have cited, nurses working alongside the villains had their suspicions. But they were afraid to report them, either for fear of litigation, reprisal or loss of employment. There is an old saying that when a nurse reports an impaired physician, the hospital fires the nurse. That is an outmoded image, but nurses are still fearful about what will happen if they report a physician or one of their own.

In addition, because — in an oddity that I can't explain — most serial killer nurses are men, gender issues come into play, and they are always tricky. And human resource professionals, who are usually charged with providing information about former staff members to prospective employers, often are intimidated into providing almost nothing other than the barest-bones facts.

Differential value of life. Although it is not a hard and fast pattern — Genene Jones, for example, killed infants and young children — many health care serial killers focus on elderly, often very sick patients, such as those on dialysis or in nursing homes or ICUs. In American society, the murder of an old, ill person often is not considered as much of a tragedy as that of a young, healthy child. However, in health care, we should not practice such discrimination. Murder is murder.

Paperwork and documentation. I used the Orville Lynn Majors story as a case study several years ago during an ethics workshop, and asked the nurses in attendance what should have been done. The response was, "Document, document, document." Those who witness suspicious behavior often believe that their only safe alternative is to have a pile of rock-solid evidence so convincing that there is no doubt whatsoever. The problem is, while others are busy documenting, patients are being killed.

No one likes paperwork — at least, no one of sound mind. And documentation can be a pain, especially for extremely busy people. So, there is a temptation to just let it go. After all, it could just be a coincidence that the mortality rate in the ICU goes up 500 per cent whenever Nurse Ratchett is on duty.

Not my silo. We are moving toward integration in health care on a variety of fronts — clinical, information technology, databases, and others — but silos are still very much a part of our landscape. After all, we tell ourselves, there are the Joint Commission, state medical and nursing boards, police and prosecutors, payers and plaintiff's attorneys. Someone will catch this guy, or woman. It really isn't my job, and I have patients to care for. The fact that those very same patients are at risk from these killers seems to escape too many practitioners.

What Can and Should Be Done?

The brunt of responsibility in this case falls on hospitals, simply because, most commonly, it is in hospitals where these predators prowl. And hospitals have not, historically, done all they could, although there has been great overall improvement over the years. Among actions that could be taken (which many hospitals and other provider organizations already have adopted) are:

Lose the denial. Like the old joke about even paranoids having real enemies, the fact is that even if we don't want to believe that a practitioner of the healing arts is injuring or killing patients, that doesn't make it untrue. Many of the murderers I have discussed impressed colleagues and patients with charming personalities, high intelligence and, apparently, superior clinical skills. Bernie Madoff is supposed to be a real charmer as well. A charming criminal, however, is still a criminal. Denial should not blind you to what is painfully obvious.

Don't let fear of litigation paralyze you. This is the most-often cited reason providers offer for not following up on suspicious behavior. I once asked some insurance executives why, when a front-page New York Times story had revealed unnecessary cardiac surgeries on a massive scale in a California hospital, their company continued to pay for cardiac care at the place. They said they could get sued otherwise.

I hear it all the time.  If we terminate this guy, he'll sue us. If we reveal that we have a rogue practitioner in our ranks, all of her patients will sue us. They'll get us on defamation. They'll get us on restraint of trade. Or whatever.

My late colleague David Manoogian, an attorney who defended providers and health plans against malpractice claims, always began his presentations by saying that he would a thousand times prefer to defend a provider that tried to protect patients than one that tried to cover up bad behavior. Although health care employers always should be wary of possibly specious or intentional misinformation, they simply cannot ignore skyrocketing mortality rates associated with one nurse or sudden deaths of healthy infants cared for by one physician. Don't wait until the pile of documentation reaches the height of Mount Everest; keep the suspect from harming patients through temporary suspension of privileges, reassignment or, at least, constant monitoring by colleagues. One simple approach is not to let them be alone with patients.

Empower intimidated staff members. Second to fear of litigation is the fear on the part of staff members that if they report their suspicions, they will face reprisals or even end up unemployed and out on the street. That's where the obsession with excessive documentation comes from.

Every organization should have a policy whereby suspicions about possible harm to patients can be reported without the witness fearing loss of employment. Obviously, there are all kinds of petty gripes, relationship squabbles and other resentments that can lead to false accusations. But the fact that not every claim is valid does not mean that they are all invalid. Develop a pathway for reporting, and that includes the ability to bypass the chain of command if the superiors of the complaining employee are involved. This should apply to all employees, including — indeed, especially — human resource professionals.

Check out all claims. It should hardly be necessary, in this day and age, to emphasize that every claim by someone seeking employment or privileges has to be checked out, whether the applicant is applying directly to the organization or the application comes through a staffing agency or verification is being done by a third party. In one of the cases I have described, a former supervisor was shocked to learn that she had allegedly provided a glowing reference for a serial killer. Not only had she never done so; she had never been contacted for any kind of information about the applicant. Just because Henry says he went to Harvard doesn't mean that he went to Harvard. And try to find out as much as you can, especially if you smell any kind of rat, no matter how light the scent.

Have a policy on concealed information. Applicants who are found to have concealed information about bad behavior should be automatically rejected. Employees who have done so should be fired. Few judges or juries will throw the book at a hospital that refused to hire or fired someone whose previous employer suspected that she was a serial killer.

Reuben Tovar, M.D., chairman of Hospital Internists of Austin (Texas), in discussing background checks, says, "Physicians are generally willing to at least consider giving their colleagues a second chance in employment and credentialing if they are forthright. Not being forthright is an automatic exclusion." Or should be.

Provide adequate information to appropriate inquiries.  If you want to get full information from any entity cited on an application, you have to return the favor. Ethicist Paul Hofmann, with whom I spoke while preparing this article, confessed his frustration with the nearly universal hospital practice of providing nothing more than "name, rank, and serial number" to prospective employers of former staff members. Often, only dates of employment are offered. That's how the Swangos and Cullens and Kwiatkowskis of this world are able to waltz from hospital to hospital, killing and infecting patients as they go. If you know something, share it. Although the Swango saga is a horrible chronicle of laxity in patient protection, at least the leadership at SUNY–Stony Brook warned every medical school and teaching hospital about the good doctor. There are times when nothing less is warranted.

Support more robust action by state entities. As I observed in my previous column, the states, historically and by constitutional law, hold most of the power when it comes to health care, from insurance regulation to licensure of professionals. And they are loath to give up an iota of it, which is one reason why Medicaid, as a "state-federal partnership," has been a simmering turf war for nearly 50 years.

Every state and territory has a medical and a nursing board, to which reports of misbehavior can be made. These boards can issue a variety of sanctions, from slaps on the wrist to loss of license. The problem is, they're all over the map in terms of how aggressive they are. In a report last year, Public Citizen — which, it must be admitted, has a long history of being very hard on providers, regulators and just about every other entity in health care — concluded that "most states … are not living up to their obligations to protect patients from doctors who are practicing substandard medicine."

The report found that in the period from 2009 through 2011, South Carolina, Minnesota, Massachusetts, Connecticut and Wisconsin, along with the District of Columbia, consistently appeared to be lax in disciplining physicians. The best states included Wyoming, Louisiana, Ohio, Delaware and New Mexico. There was similar variance in the quality of state boards' websites and levels of transparency, although, as the report noted, "A good website is no substitute for a poor disciplinary rate (or vice versa)."

And there is a further problem. Although the data — and the article, for that matter — are a bit long in the tooth, a 2007 piece in the Journal of Health Politics, Policy and Law by Grant D. Alfred found that "there are a very large number of repeat offenders among physicians who have received board sanctions, indicating a possible need for greater monitoring of disciplined physicians or less reliance upon rehabilitative sanctions."

The state boards have to do their jobs, and they should be encouraged to do them as robustly as possible.

Consider the pros and cons of a national database. One way to get around lackadaisical state regulation would be to have a national database on all health care professionals that included information on employment, complaints, firings, imprisonment, state board sanctions, and the like. This, of course, opens a can of worms that would feed all the fish in the sea. The states would fight the idea tooth and nail and it literally would require an act of Congress, which would be intensely lobbied by a variety of interested parties not to pass it.

On the one hand, a national database would certainly limit the ability of serial health care killers to migrate from one state, when things got too hot, to another where nothing is known about them. On the other hand, if control over monitoring of health care professionals passes from the states to the feds, and the feds choose, for whatever reason, not to pursue the effort vigorously, then the states would be helpless and there would be no protections.

This is all theoretical because, at least for the foreseeable future, such a registry would never be approved. But perhaps a middle ground would be a means whereby states could at least exchange information with each other when a problem arises. There is no excuse for an obvious addict gaining employment in 19 different hospitals partially because they were not all in the same state.

Be aware that these crimes touch — and demean — us all. If your organization is doing everything that is recommended, and preferably more, then good for it! But not all providers or insurers or others are doing so. Like infections, serial killers seek the weakest link — the provider with lax oversight, the ineffective state medical or nursing board, the organization too afraid of lawsuits to do much of anything.

In the "60 Minutes" interview, Charles Cullen was remarkably frank about how easy it was for him to get away with all those killings. At Saint Barnabas Medical Center in Livingston, N.J., where he spiked IV bags with overdoses of insulin, he told CBS reporter Steve Kroft, "They could've had my license investigated and probably revoked. They should have."

He gained employment at St. Luke's University Hospital in Bethlehem, Pa., after being forced out of five other facilities and having murdered at least 11 patients; his total kill at St. Luke's was five. Asked if he thought St. Luke's officials were onto him, Cullen replied, "I think that they had a strong suspicion." He added, chillingly, "I think you can say I was caught at Saint Barnabas, and I was caught at St. Luke's. There's no reason that I should've been a practicing nurse after that." Instead, he says, "They said, ‘If you resign, we'll give you neutral references.'" And off he went to kill again. Even at the end, Somerset Medical Center, in Somerville, N.J., where he was finally stopped, was accused by police detectives of hindering their investigation.

In an online blog about the Orville Lynn Majors case, a patient-safety advocate who goes only by the name of "Joel" wrote, "If no one in medicine knew Majors was murdering patients for the first 50 or 100 murders, it is because medicine defiantly refuses to care about or know about the long-term results it creates for patients. Medicine doesn't learn even from lethal events."

Let's do whatever is necessary to prove him wrong. Our patients deserve it. Our caring colleagues deserve it. And our field deserves it. As John Donne wrote, "No man is an island." As long as even one of these killers operates with impunity among us, we are all demeaned. And we all share their guilt.

Part 2: "The Overprescribers" (Feb. 4, 2014)

Copyright © 2013 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express.