"When Silence Kills" (Editorial, February) reminded me of my earliest experience with malpractice. I was a new nurse working in a nursing home, and I witnessed a certified nursing assistant (CNA) threaten a patient, warning that she could restrain him and lock him in his room. The patient and I were obviously taken aback and, like Diana Mason, I was appalled and enraged. But the CNA laughed off my concern, saying it was "just a joke." I reported her actions to the charge nurse. She, too, laughed and dismissed the incident. I've always regretted not doing more to protect this patient, but I believed I was the only nurse ever caught in this dilemma.

Nurses must discuss the malpractice they've witnessed. Once they know others have been in similar situations and will support them in reporting it, more nurses will come forward. I hope we can one day learn to break this unwritten code of silence.

Elizabeth O. Adeyinka, RN

Brooklyn, NY

I was a nurse for 32 years, and in that time I witnessed several cases in which silence killed. I, too, have been guilty of not speaking up.

Four years ago, I started voicing my opinions-and immediately became the most unpopular nurse in my facility. Soon after, I left the field of nursing. I had witnessed the death of a 37-year-old caused by malpractice, denied a drunk surgeon access to the operating room-while other physicians refused to intervene-where he was going to perform surgery on a seven-year-old with a ruptured appendix, and seen a physician insert a chest tube without any sedation after a patient with a collapsed lung responded affirmatively to the physician's question of whether he smoked.

I understand nurses want to keep the peace and keep their jobs, but our silence is killing patients. We must offer help to the offenders, but the patient also needs protection-as does the nurse, who should be able to go home each night proud of her work.

Name withheld upon request

While I understand Diana Mason's dismay at people not reporting Charles Cullen for his actions, I am more than moderately alarmed at the prospect of the proposed changes to the National Practitioner Data Bank (NPDB) that would allow us to "track nurses who are fired or charged with malpractice."

A nurse's licensure history and information on relevant legal issues should indeed be available to prospective employers, and it currently is. As for any proposed changes to the NPDB, we must first understand that malpractice allegations are just that-allegations. Everyone is innocent until proven guilty. This protects a person's right to work; nurses have been fired for many reasons, including not complying with objectionable corporate policies (including dangerous practice conditions or morally objectionable situations) and because they didn't "fit in" at the institution. I have seen nurses fired at the whim of a CEO.

Some nurses are fired because they "make too many errors." As a quality-improvement professional, I know nursing errors don't usually happen in isolation from system processes. Nurses bear the burden of being on the front line. The reasons they lose their jobs are as numerous as the reasons they retain them-and sometimes just as arbitrary.

Sacrificing employees' rights starts us down a dangerous path. Preventing crimes such as Cullen's includes tracking data concerning practice, tracking and analyzing patient deaths, and being aware of our coworkers' actions. These are management responsibilities, and managers should take them seriously. I put the burden of Cullen's ability to do away with patients on the backs of his managers.

Mary Ramos, PhD, RN

San Antonio, TX

Like Diana Mason, I was complicit in the code of silence in the past. I am still haunted by my memories.

I firmly believe in the role of regulatory agencies and their various tracking and reporting mechanisms, but nothing can substitute for each nurse living by the ANA's Code of Ethics for Nurses with Interpretive Statements. Nurses are not saints, but we do bear a greater ethical burden than many other professionals do. Whether we're discussing Cullen or the many RNs who have failed to ensure patient safety, I believe many nurses suspected or knew what was happening. The best way to protect our patients and ensure the best care is to hold ourselves and one another accountable.

I join you in applauding the nurses in the Cullen case who stood up for the values of our profession.

Susan King, MS, RN

Portland, OR

I am deeply disturbed by Diana Mason's editorial. I wasn't a nurse 30 years ago, but some of my colleagues were. When I related your story, they assured me that it's always been clear that your duty is to report a colleague for neglecting and causing the death of a patient.

Diane E. Allen, BSN, RN,BC

Manchester, NH

Just last year, an LPN at a local health care facility was reportedly allowed to resign after she was discovered to have been practicing for more than 25 years without a license. Apparently, the facility has yet to follow through on a report to the licensing or regulation board.

I have suggested to my coworkers that we start notifying our supervisors in writing of incidents that demonstrate unsafe nursing or inadequate education. Written complaints might be harder to ignore than verbal ones, which can be denied or forgotten.

The situation is so bad that several nurses and I have decided that our family members will not be treated at any local facility unless we are constantly with them. This would include not allowing any medications to be administered unless we witness the drug being opened and prepared.

I am proud to be a nurse but terrified of where we are heading.

Name withheld upon request

Nurses also practice another type of silence. Once a physician has pronounced a diagnosis and predicted an outcome, nurses often just follow orders, perhaps to protect themselves and perhaps because they've never been patients and can't appreciate their vulnerability.

It's difficult but necessary to question physicians and hospital policy. One day while working in the ICU, I asked my fellow nurses, "If your child or husband were here, would you put up with being allowed to be here only 15 minutes every two hours?" No, they said, and they wouldn't have to. Nurses can get around the rules. That's what we do for one another.

We are patients' advocates, but what exactly are we advocating? Until we can answer this, patients will be left to fend for themselves, and we will ignore their real needs.

E. S. Johnson, BSN, WHNP

Atlanta, GA

The editorial serves to remind us all that cheating, lying, and stealing are wrong and should be reported. It should also remind every facility's administrators that they must listen to complaints and investigate instead of ignore them.

Susan J. Roti, RN, BC

Panama City, FL