Intentional Harm

Recognizing and Responding to Potential Harmful Behaviors in Healthcare Settings

• In 2016, an Ontario RN admitted to murdering eight long-term care residents. While such cases are rare, all nurses and managers must stay alert to unusual behaviors or unexplained patient harm.
• Colleagues had noticed the nurse acting strangely or unprofessionally at work.
• Insulin was used to harm residents, sometimes taken from one patient to overdose another. Other substances used by health care serial killers include sedatives, opiates, potassium, and anesthetics. Any discrepancies in medication supplies should be investigated.
• If a nurse’s behavior seems reckless or intentionally harmful, it must be followed up on.
• A pattern of serious incidents linked to one nurse—especially involving stable residents—should raise concern. These events may seem like “bad luck” but could indicate intentional harm.
• Some cases are uncovered through mortality reviews or staff reporting suspicious activity. Everyone has a role in ensuring safe care.
• Internal investigations may lead to reporting to the CRNS or police if professional misconduct is found.

 What are the professional expectations of practice for RNs in this context? 

 Registered Nurses:

• Are accountable and accept responsibility for their own actions and decisions (1).
• Practice in accordance with agency policy and legislation, and in a timely manner, recognizes and reports near misses and errors (own and others), adverse events and critical incidents, and take action to stop and minimize harm (2).
• Recognize and address professional practice, legal or ethical violations by themselves or others in a timely and appropriate manner (3).
• Report to employers and/or the appropriate regulatory body concerns related to professional incompetence, professional misconduct and/or incapacity of registered nurses and/ or other health care providers (4).
• Take measures to maintain fitness to practice ensuring client safety is not compromised (5).
• Demonstrates a professional presence, and confidence, honesty, integrity and respect in all interactions (6).
• RNs are expected to advocate for high standards of care and improvements in the health care system at all levels in the best interest of clients, especially when they are unable to advocate for themselves (7).
• Engage in safe medication management practices, including having authorization and requisite knowledge, skill and judgment (8).
• Maintain and keep clear, complete, accurate and timely documentation. RNs do not document false or misleading information (9).
• Act with integrity in clients' best interest (10).
• Do not physically, verbally, emotionally, financially or sexually abuse, harass or neglect their clients (11).
• Strive to protect clients from any type of harm, neglect or abuse. This includes taking action to stop and refrain from unsafe, incompetent, unethical or unlawful practice (12).
• Are truthful in their professional practice. Speaking or acting without intending to deceive. Truthfulness also refers to giving accurate information. Intentional omissions are as untruthful as false information (13).
• Do not engage in any acts of professional incompetence and/or professional misconduct and report any concerns related to these and/or fitness to practice and comply with the duty to report as outlined within The Registered Nurses Act, 1988 (14).
• Cooperate with the CRNS, including cooperation in professional conduct processes and offering complete and accurate information (15).

CRNS Resources 

Code of Conduct (2026)

Registered Nurse Practice Standards (2026)

Registered Nurse Entry-Level Competencies (2026)

Website content link for Professional Conduct

 External Resources 

College of Nurses of Ontario Rare but Real: Intentional Harm to Patients videos

A Regulatory Response to Healthcare Serial Killing article in the Journal for Nursing Regulation, 2019