Petr Zelenka, a nurse at an east Bohemian hospital, wanted to conduct a test: How long would it take doctors to realize he was killing patients?

Zelenka, 30, gave this as the reason behind a spree that killed eight patients at Havlíčkův Brod Hospital this year when he was arrested and confessed to the crimes Dec. 1.

He is now behind bars, charged with eight murders and nine more attempts, and could face a life sentence, although lawyers say he is unlikely to get more than 15 years.

But the fallout from the case continues, largely because the answer to Zelenka's question has become apparent: far too long.

Doctors at Havlíčkův Brod first suspected that Zelenka could be connected with a series of unusual deaths in May, but didn't file a criminal complaint and fire him until September. Between his sacking from Havlíčkův Brod and his arrest, Zelenka even managed to get another nursing job, at Jičín Hospital in east Bohemia; administrators there weren't warned about him and didn't suspect a thing.

As an investigation continues, health experts and patients' rights groups are questioning the system that allowed the nurse to carry out his crimes, saying not only did Havlíčkův Brod managers err by not acting sooner, but that the case points to a weak system of safety controls.

"A flawed system is at the root of least 95 percent of all medical mistakes," says David Marx, head of the Czech Association for Quality in Health Care. "In a well-functioning hospital anything unusual should immediately set off alarms. This didn't happen here."

Health Minister Tomáš Julínek set up a special committee Dec. 6 to look into the case. Doctors at Havlíčkův Brod are under investigation, and the hospital's director, Josef Pejchl, was sacked for taking too long to fire Zelenka.

A 'determined murderer'

Patients' rights groups are divided on the issue. Pavel Vepřek, head of the Czech Health Forum, which promotes healthcare reforms, said neither the Havlíčkův Brod doctors nor the system were at fault.

"These were the criminal acts of one individual. You can't blame it on the system," he said. "I don't think there exist any safety measures anywhere in the world that can protect patients against a determined murderer."

Czech Patients Association President Luboš Olejár, on the other hand, said that Zelenka's case is an example of shortcomings in safety checks and security measures at Czech hospitals.

"It's absolutely outrageous," he said. "Something as simple as careful documentation of the amount of drugs each patient is given could have prevented this tragedy. There are clearly holes in the system, but the doctors involved are also responsible."

In May, Pavel Longin, the Havlíčkův Brod hospital's head doctor, noticed that an abnormally. high number of patients in the intensive care ward were bleeding to death. He discovered that unusually high doses of Heparin, a common blood thinner, the use of which typically goes undocumented in hospitals, were causing the bleeding.

Zelenka's name surfaced as the last nurse to care for the deceased.

Longin told the daily Mladá fronta Dnes that he feels that his conscience is clear and he could not have acted sooner because he lacked direct evidence implicating Zelenka.

Ondřej Dostál, a lawyer who specializes in bioethics, says the doctors may face charges if it is proven that they could have prevented deaths.

"According to law, anyone who suspects that a crime is about to take place is obliged to try and prevent it," Dostál said.

The Havlíčkův Brod district police department is also under investigation. The police received the criminal complaint against Zelenka Oct. 23, more than a month before they arrested him.

Stricter controls

Meanwhile, the Health Ministry is promising a stricter system of controls at hospitals, starting with the demand that they obtain either national or international accreditation, which is currently not mandatory.

Paradoxically, the Czech Health Care Institute rated Havlíčkův Brod the top hospital in the Vysočina region and the eighth-best hospital in the country this November for its outstanding level of care.

Longin says, however, that the hospital doesn't have any formal system of controls in place that could have prevented the crimes from happening.

Some doctors like Marx say accreditation would help.

Only two Czech hospitals, Na Homolce Hospital and the Central Military Hospital — both in Prague — have international accreditation. Eight more are accredited nationally.

Marx says that by the end of next year 30 new hospitals should fulfill the requirements for national accreditation, ranging from building safety to data storage and employee screening.

Havlíčkův Brod isn't one of them.

Marx adds that more thorough documentation of medication distribution is needed.

Requiring two nurses to be present when a patient receives any medication might also be a good idea, according to Marx.