Anyone in a health care facility can become a victim of violence. Since January 2010, The Joint Commission has received 185 reports of violent criminal events from its accredited organizations. Of these, 102 were patient-on-patient violence (61 rapes, 22 homicides and 18 physical assaults). Six of the physical assaults were patient-on-staff violence. Half of the 185 reports were committed by and/or on behavioral health/psychiatric patients, or in a behavioral health setting.
The majority of homicides and physical assaults involved beating, punching or kicking, or strangulation or asphyxiation. Of the injuries sustained, the most common were head injury, head trauma, or eye injury. Of the 28 reports of physical assault, six resulted in the death of the victim and six resulted in permanent loss of function.
Safety Actions to Consider:
While risk factors for violence vary depending on the facility and the patient population, the following general prevention strategies may be considered, especially if your organization’s patient population includes behavioral health or psychiatric patients.
Identify risks and plan to reduce those risks:
- ♦ Form a multidisciplinary committee (such as the environment of care or safety committee) that includes direct-care staff and union representatives (if available) to identify risk factors in specific work scenarios and to develop risk reduction strategies.
- ♦ Conduct a risk assessment of the organization, including geographic location and service area, as violent offenders may travel to your site seeking services.
- ♦ Conduct an assessment of risks associated with the patient population. Periodically reassess for those risks and any new risks.
- ◊ In non-acute care settings, determine admission and exclusionary criteria for patients who have a history of violence and who pose a risk to existing patients and staff.
- ♦ Survey employees to determine how safe they feel while working, and how prepared they are for handling violent situations.
- ♦ Maintain an ongoing dialogue with local law enforcement regarding risk factors in the community (for example, gangs), and the local crime rate. Although the facility may be located in a low crime area, patients and their families may be from other areas.
- ♦ Implement a comprehensive violence prevention program and periodically evaluate the program.
- ♦ Implement a plan to address identified risks and update the plan as new information is presented. For example:
- ◊ Hospitals may consider having the security lead on each shift meet with the charge nurse on each open unit to dialogue regarding emerging issues, or may instruct EMTs to take rival gang victims to separate hospitals (if clinically appropriate).
- ◊ Behavioral health care programs may consider having a daily shift meeting to alert the team about risk factors related to newly admitted patients or new risk factors in the existing patient population.
- ◊ Community and home-based programs may consider changing the locations for providing service when there are risks present in the area in which a patient’s home is located.
- ♦ Develop emergency signaling, alarms, and monitoring systems.
- ♦ Install security cameras and panic buttons.
- ♦ Improve lighting in hallways, rooms, clinical offices and parking areas.
- ♦ Provide security escorts to the parking lots at night.
- ♦ Design the triage area and other public areas to minimize the risk of assault.
- ♦Some strategies may include:
◊ Provide staff restrooms and emergency exits.
◊ Install enclosed nurses’ stations.
◊ Install deep service counters in, or enclose, reception areas.
◊ Arrange furniture so that staff can easily access the closest exit.
◊ Minimize the presence of objects that could be used as weapons.
◊ Make waiting areas comfortable and accommodating.
- ♦ Restrict the movement of the public by using card-controlled
- ♦ Design staffing patterns to prevent personnel from working alone and to minimize patient waiting time.
- ♦ Develop a system for alerting security personnel and other staff when violence is threatened.
- ♦ Flag charts of patients who have exhibited prior violent behavior.
- ♦ Establish a “zero tolerance” expectation for threatening and violent behavior and communicate how this behavior will be addressed up to and including discharge or transfer from care.
- ♦ Consider establishing a police check-in station or substation.
- ♦ Work with local law enforcement to provide employees with crime prevention training.
- ♦ Train staff to recognize and manage assaults, resolve conflicts, and maintain hazard awareness. Training should address how to manage crises with potentially volatile patients and visitors, especially those under the influence of drugs or alcohol, or those who have a history of violence or certain psychotic diagnoses.
- ♦ Provide staff with tips on how to be alert and cautious when interacting with patients and visitors.
- ♦ Familiarize staff with policies, procedures and materials on violence prevention.
- ♦ Provide a culture where employees are comfortable reporting events to management, security and law enforcement.
Plan for post-event activities
- ♦ Provide an environment that promotes open communication.
- ♦ Develop written procedures for reporting and responding to violence.
- ♦ Offer and encourage counseling whenever a worker is threatened or assaulted.
- Centers for Disease Control and Prevention (CDC): Workplace Violence Prevention for Nurses
- CDC: Training and Education Workplace Violence Prevention for Nurses
- CDC: United States Government Occupational Violence Links
- CDC: Violence Occupational Hazards in Hospitals (includes prevention strategies)
- Kathleen M. McPhaul, et. al.: “Environmental Evaluation for Workplace Violence in Healthcare and Social Services.” Journal of Safety Research, Volume 39, 237-250, March 2008
- National Association of Psychiatric Health Systems: Design Guide for the Built Environment of Behavioral Health Facilities, Edition 6.2, March 25, 2014, www.naphs.org
- National Research and Training Center (NRTC): Crisis De-Escalation Training for Staff and Consumers in Inpatient and Other Service Delivery Settings
- The Joint Commission: Sentinel Event Alert Issue 45: Preventing violence in the health care setting, June 3, 2010
- The Joint Commission: “Security safety: Employee training lowers violence risks at hospitals.” Environment of Care News, Volume 15, Issue 3, March 2012
- The Joint Commission: “Violence code reload: Ft. Lauderdale hospital launches successful new violence prevention program.” Environment of Care News, Volume 16, Issue 11, November 2013
- The Joint Commission: “Engineering solutions to workplace violence: Prevent workplace violence via safety-enhancing design and equipment.” Environment of Care News, Volume 17, Issue 3, March 2014
- The Joint Commission: Quick Safety Issue Four: Preparing for active shooter situations, July 2014
Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert. The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations. The information in this publication is derived from actual events that occur in health care.
©The Joint Commission, Division of Health Care Improvement