HEALTHCARE RISK CONTROL SYSTEM

Violence in Healthcare Facilities

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VOLUME 2
Violence in Healthcare Facilities
When violence erupts in a healthcare facility, the con-
sequences are many and unpredictable. Injury or
death of building occupants; lawsuits; property dam-
age; and diminished patient, staff, and community
trust in the facility are a few possible consequences.
While healthcare facilities in urban areas with high
crime rates may be more prone to violent events, even
in suburban and rural locales, the risk of workplace
violence looms in healthcare facilities—where a stress-
ful work environment can quickly become volatile,
visitors are often highly emotional, and drugs or ex-
pensive equipment may become targets of robbery.
Abortion clinics and healthcare facilities with animal-
research laboratories face the unique challenge of
being targeted by protestors who may turn violent.
Although the overall rate of crime in healthcare
facilities declined in 2003, continuing the trend seen
during the late 1990s, the number of reports of violent
events remained level, according to the International
Association for Healthcare Security & Safety’s 2003
survey on crime in hospitals.1 Data from the Joint
Commission on Accreditation of Healthcare Organiza-
tions’ (JCAHO) Sentinel Event Statistics database
paints a slightly more alarming picture: JCAHO re-
ceived 24 reports of events involving assault, rape, or
homicide in 2004, up from 4 such events reported in
2003 and 17 events, the second-highest annual num-
ber, reported in 1999.2 This data must be viewed with
the generally accepted philosophy that underreporting
of violent events in healthcare facilities is widespread
and common.
Many violent events in healthcare facilities, particu-
larly assaults on staff members, are caused by patients;3
however, this Risk Analysis focuses on violence com-
mitted by visitors, employees, or trespassers (e.g., rob-
bery, stalking of a patient or employee). The Healthcare
Risk Control (HRC) System includes a separate Risk
Analysis devoted entirely to violence caused by pa-
tients. “Patient Violence” is located in the Mental Health
section of Volume 4 of the HRC System.
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Risk Analysis
Safety and Security 3
Of course, it is impossible to completely eliminate
workplace violence in healthcare facilities. The unex-
pected can unfold in a heartbeat—consider a 2003 inci-
dent at a Boston, Massachusetts, healthcare facility in
which a laboratory worker inexplicably shot a physi-
cian to death and then killed herself.4 However, there
are ways to reduce the potential for violent occur-
rences, as well as strategies for minimizing the impact
of any violent situation that may arise. Healthcare risk
managers should collaborate with security personnel
to identify areas of the facility and its campus that are
vulnerable to violence and to ensure that healthcare
workers and other appropriate employees are trained
in violence de-escalation and the procedures for re-
sponding to violent individuals. Collaboration with
the human resources (HR) department and supervi-
sors is also important. The HR department can help
protect the facility against violence by supporting
strict criminal background checks and ensuring fair
and consistent hiring, firing, and discipline practices.
HRC TOOLS FOR THIS TOPIC
______________________________
The following tools and resources on this topic are
available in your HRC System. Refer to this article and
other HRC resources for help.
q Sample Policy
q Self-Assessment Questionnaire
q Checklist
q Case Law
q Resource List
q Action Recommendations
q Also Available on HRC Web Site
September 2005
Healthcare Risk Control
Supervisors can help foster a work environment in
which employees feel comfortable reporting when they
experience domestic violence that could spill over into
the workplace, have become the target of a stalker or of
harassment, notice suspicious coworker behavior, or
are otherwise concerned that a threat of violence exists.
This Risk Analysis covers these topics and presents
strategies for preventing violent occurrences, for man-
aging events as they unfold and during the aftermath,
and for training employees in violence prevention and
response. It also includes a sample policy on work-
place violence prevention and response (see Appendix)
and a chart to aid healthcare workers in de-escalating
potential violence from patient visitors.
Requirements, Guidance, and Standards
JCAHO
Under Environment of Care standard EC.2.10, JCAHO
requires accredited facilities to address the risk of
workplace violence. Among the requirements are
those for facilities to maintain a written plan describ-
ing how security of patients, staff, and facility visitors
will be ensured; to conduct proactive risk assessments
considering the potential for workplace violence; and
to determine a means for identifying individuals on its
premises and controlling access to and egress from se-
curity-sensitive areas.5 Regardless of whether a facility
is JCAHO-accredited, these measures are all essential
for a strong violence-prevention program.
OSHA
In 2004, the Occupational Safety and Health Adminis-
tration (OSHA) released an updated guidance docu-
ment on preventing violence in the healthcare setting.
The guidelines are advisory in nature; failure to im-
plement them will not result in a citation. However,
OSHA states, “Employers can be cited for violating
the General Duty Clause if there is a recognized haz-
ard of workplace violence in their establishments and
they do nothing to prevent it or abate it.”6 OSHA
specifies that the guidelines focus on preventing pa-
tient violence, but many of the recommendations (e.g.,
those related to training staff and ensuring physical
safety of the facility) can help guard against violence
committed by other perpetrators. A PDF version of the
guidelines is available at http://www.osha.gov/
Publications/osha3148.pdf. Appendix B to OSHA’s
guidelines contains sample forms for reporting violent
incidents; these forms are reprinted in Safety and Secu-
rity 3.1 of the HRC System.
2 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Safety and Security 3
Violent events that result in worker or staff injuries
requiring treatment beyond first aid and/or days away
from work must be reported to OSHA, as required by
the agency’s standard for reporting and recording
work-related illness and injury.7 Employers must re-
cord these injuries in the OSHA Form 300 Log of
Work-Related Injuries and Illnesses. Keep in mind that
an event resulting in worker fatality or the hospital-
ization of three or more workers must be reported
to OSHA within eight hours. More information on
OSHA’s record-keeping standard is included in the
Risk Analysis titled “OSHA Illness and Injury Record-
Keeping Standard” in Supplement A of the HRC System.
Liability
Foreseeable Risk/Special Relationship
A healthcare facility can be held liable for its failure to
provide adequate and reasonable security. Foreseeable
risk is often a significant factor in cases alleging inade-
quate security. For reasons of liability (not to mention
patient and staff safety), this potential allegation is why
it is so important for the healthcare facility to imple-
ment preventive measures as soon as the potential for
violence is identified. If, for example, areas of the cam-
pus are documented as having poor lighting and inade-
quate security monitoring after a physical walk-
through assessment, steps should be taken immediately
to correct these deficiencies. If corrective actions are not
taken, the facility could be accused of failing to take
proper precautions in the face of a foreseeable risk
should a violent incident be tied to such conditions.
Foreseeability can be based on the facility’s own
experience. If the facility has had similar occurrences
on its premises in the relatively recent past, it may
be foreseeable that they will continue to occur.8,9,10
Foreseeability can also be shown by a “totality of the
circumstances” test. This may allow an assault to be
foreseeable if, for example, a number of rapes have oc-
curred in other local healthcare facilities, although
none have occurred at the facility in question. How-
ever, the circumstances must lead one to the conclu-
sion that a crime of this particular type may occur.
Another factor in cases alleging inadequate security
is the “special relationship” that exists between the
hospital and a patient. The Alabama Supreme Court
cited this relationship in reversing a lower court
ruling and finding for a patient who was sexually
assaulted in her hospital bed while under heavy seda-
tion. The court based its decision on the general rule
of premises liability, which states that, absent a special
September 2005
Safety and Security 3
relationship or circumstances, an owner or occupier of
premises may not be held liable for the criminal acts
of third parties. The patient’s case fell under the spe-
cial-relationship exception because in her heavily se-
dated state, she was unable to protect herself from the
assault. The special relationship between the hospital
and the patient legally obligated the hospital and its
security service to protect the patient from the crimi-
nal acts of third parties.11
Electronic measures to increase the physical secu-
rity of a healthcare facility are described in “Enhanc-
ing Physical Security.”
Negligent Hiring and Supervision
Depending on state law, a victim of violence committed
by an employee may allege negligent hiring against
the healthcare facility. In deciding whether negligent
hiring was at issue, courts usually consider whether
· the employer knew or should have been aware of
the employee’s violent tendencies,
· the victim was owed a duty of care, and
· a causal connection exists between the injury and
the perpetrator’s employment.12
In 2004, a Kentucky jury awarded $2.09 million to a
woman who was raped by an employee while she was
a patient at a mental institution. The lawsuit alleged
that the hospital failed to provide a safe environment
and had been negligent in hiring the employee because
it did not check his references. Indeed, the employee
had been fired from his last place of employment for
intimidating patients, and he had listed this previous
employer on his job application. That hospital was
never contacted for a reference. Also, two weeks before
the rape occurred, a staff member had reported to facil-
ity management that the employee made sexual com-
ments to various staff members, but the hospital took
no action, the lawsuit alleged. Although the hospital ar-
gued that it had not violated any legal duty to its pa-
tients when it hired the employee, the jury found the
hospital negligent.13
Under the liability theory of negligent supervision,
employers may be held liable for the injurious actions
of a violent employee. This theory could apply if the
court determines that the employer failed in its duty
to supervise employees adequately enough to prevent
them from intentionally harming others.14
Lawsuits Filed by Individuals Accused of Violence
Healthcare facilities must also be aware of the possi-
bility of facing lawsuits from individuals accused of
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
violent acts or tendencies. These lawsuits may allege
false arrest/imprisonment or use of excessive force.
Risk managers should work with security managers to
ensure that training for security personnel encom-
passes appropriate use of force.
If the alleged violent perpetrator is an employee,
healthcare facilities must proceed with caution regard-
ing the handling of such an allegation. Employers that
warn potential victims or prospective employers that
an individual has violent tendencies but have no evi-
dence to support the allegation could face a defama-
tion lawsuit. Fear of being sued for defamation may
prevent many healthcare employers asked to provide
employment references from disclosing information
regarding a worker’s incompetence or violent behav-
ior. This reluctance was cited as one factor that en-
abled a nurse who killed patients at multiple facilities
to repeatedly gain employment despite documented
incompetence and suspicious behavior, such as stock-
piling lethal medication. 15 The case prompted New
Jersey and Pennsylvania, the states in which the kill-
ings occurred, to pass laws protecting healthcare
providers from civil liability when they disclose mis-
conduct or incompetence by healthcare workers to
state licensing boards, state regulators, and prospec-
tive employers. The case is discussed in further detail
below; see “Healthcare Workers Who Harm Patients.”
Invasion of privacy is another liability exposure.
For example, if a healthcare facility investigates an
employee’s personal life under the suspicion that the
employee poses a threat of violence, the employee
could sue for invasion of privacy. Legitimate reasons
for the investigation must be established.16
Defining Violence
Before a healthcare facility can determine its risk of vi-
olence, it must define violence. The National Institute
for Occupational Safety and Health defines workplace
violence as “violent acts (including physical assaults
and threats of assaults) directed toward persons at work
or on duty”17 (emphasis added). Broadening the defi-
nition to include verbal threats of violence or threaten-
ing behavior can prompt more frequent employee
reporting of perceived potential for violence. Many
studies have found that employees often fail to report
potentially violent behavior due to a lack of knowl-
edge regarding what actions the facility considers to
constitute violence. Examples of violence include, but
are not limited to, beatings, stabbings, suicides, shoot-
ings, rapes, near-suicides, and behaviors that can
cause psychological trauma, such as threats, stalking,
3
Healthcare Risk Control
Enhancing Physical Security
Physical security’s primary functions in a healthcare facil-
ity—access control and surveillance—play a major role in
reducing the chance for a violent event to occur. Tradi-
tional nonelectronic measures, such as installing fences
and locks, strengthening windows and doors, and main-
taining a key inventory are, of course, still useful in many
cases. The electronic measures described below fall into
three categories: closed-circuit television (CCTV) systems,
intruder and holdup alarms, and access-control systems
requiring possession of a code, a card, or a physical char-
acteristic measurable by a biometric system.
Closed-Circuit Television Systems
CCTV systems can be a valuable tool in helping to pro-
tect staff, patients, visitors, and property. This is particu-
larly true when healthcare facilities “do their homework”
and install a system appropriate for the facility and its se-
curity staff.1 The systems permit a healthcare facility to
detect and, often, to record certain types of activity, and
the presence of visible cameras may also serve as a psy-
chological deterrent to crime. (Some healthcare facilities
have used dummy cameras that provide only this psy-
chological deterrent. The false sense of security imparted
by dummy cameras or unmonitored/malfunctioning real
cameras has been the basis of many lawsuits.)2 Healthcare
facilities often use CCTV systems for surveillance, and ac-
cess-control applications are becoming more common in
areas such as the emergency department and other build-
ing entrances, pharmacies, receiving docks, physician of-
fices, computer rooms, and parking lots. For instance,
access control might include use of a camera to review
obscene phone calls, physical intimidation, and ha-
rassment of any nature, such as following, swearing
at, or shouting at others.
Another definition breaks workplace violence into
the following three categories:18
· Physical assault (includes attacks ranging from slap-
ping and hitting to the use of weapons and resulting
in any degree of injury, from no injury to fatal injury)
· Threats communicated verbally or by letter, tele-
phone, or e-mail (includes the expression of intent
to cause physical harm, which may be psychologi-
cally traumatic even if never carried out)
· Harassment (includes the creation of a hostile envi-
ronment through unwelcome actions, physical
contact, and/or words, such as insults and other
comments intended to belittle a person, not in-
tended to result in physical harm)
4 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Safety and Security 3
visitors seeking entrance at a door with remotely oper-
ated locks.
The design of a CCTV system should be appropriate to
the potential threats identified in a security assessment,
and it may also be prudent to design the system to permit
appropriate expansion as the healthcare facility’s security
needs evolve and expand. If budgetary constraints are an
issue, the system can be designed so that essential compo-
nents are purchased first and other items are added as
funding permits. For some systems, it may be appropriate
to install backups for key cameras, cables, and other equip-
ment. Such redundancy may reduce downtime at key cam-
era locations and service costs in the long run. When
running backup cable, using a route different from that of
the primary cable may reduce the risk that both lines will
be damaged or cut at the same time.
The healthcare facility must decide when, where, and
by whom recorded images will be reviewed. Some facili-
ties review tapes only after an event is reported, requir-
ing long video storage; some review everything, which
can be time-intensive unless recording is alarm-triggered;
and some review tapes randomly.
Alarms
Alarm systems are the second major category of elec-
tronic physical-security devices. Healthcare facilities use
two basic types of alarm systems: intrusion alarms and
holdup (or panic) alarms. Intrusion alarms are often
found in areas within the facility that must be closed for
certain periods (e.g., pharmacies, general stores). Holdup
alarms are often used in cashiers’ offices, pharmacies, and
Healthcare facilities should adopt and enforce a
zero-tolerance approach toward all forms of violence.
Violence Reporting System
Employees should be educated on the facility’s defini-
tion of what constitutes violence and encouraged to
report to their supervisor or other designated individ-
ual anything they perceive as a warning sign of vio-
lence. Many violent acts go unreported. Employees
may fear supervisors will blame them for or minimize
the seriousness of the incident; they may also be reluc-
tant to cause tension, or they may blame themselves.
To reduce these fears, the violence-prevention policy
should state that discrimination against victims or re-
porters of violence is not permitted and that all poli-
cies concerning violent events will be applied
consistently to all healthcare workers and staff
members.
September 2005
Safety and Security 3
gift shops and are used more often as panic alarms to
summon security personnel. Panic alarms are commonly
used in psychiatric areas, emergency departments, and
remote work locations. Healthcare risk managers should
also consider using them in work areas of employees or
staff members who are potential victims of violence, such
as those who identify themselves as victims of stalkers or
of domestic violence.
False alarms should be analyzed. They are more often
the result of personnel errors than of malfunctioning
equipment. Too many false alarms can result in alarm
systems being disconnected and may alter police
response.
Electronic Access Control
Existing methods of electronic access-control methods
rely on three basic forms of identification. The user must
be in possession of a piece of information (e.g., a personal
identification number), a physical key (e.g., a magnetic-
stripe card), or a biometrically identifiable personal char-
acteristic (e.g., a fingerprint).3 Access-control methods
must be adjusted to reduce the number of unauthorized
personnel admitted and, at the same time, the number of
authorized personnel not admitted. Information-based
systems have low levels of false acceptance and false re-
jection but rely on the user to keep the code secret. Sys-
tems requiring a physical key are generally reliable,
although the key can be lost or damaged.
Code systems are usually easy to program and use.
Along with user vigilance, the security of the code de-
pends largely on its length—the higher the number of
digits in the code, the greater the number of possible
combinations and thus the lower the chance that an
The reporting system should include forms for
employees to describe the violent event or perceived
threat of violence. (See “Guidelines for Preventing
Workplace Violence for Healthcare and Social Service
Workers,” located in this section of the HRC System,
for sample violent-incident report forms. The forms
are also available in the sample policies library on
the HRC Members’ Web site; log on http://www.
ecri.org.)
A hotline should also be established for this pur-
pose. The system should protect the confidentiality of
employees who make written or verbal reports. All re-
ports should be documented and should result in im-
mediate action. A perceived lack of follow-up to
reports of violence will result in underreporting.19 In-
creasing the frequency of violence reporting will better
equip the healthcare facility to implement measures
effective in reducing the risk of violence.
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
intruder will enter the correct code. Codes should be
changed regularly.
Biometric systems work by measuring a unique per-
sonal characteristic during an enrollment process, then
using this information to create a template, which identi-
fies the individual in future encounters by matching new
measurements of the same characteristic.4 No other type
of security system provides as certain a guarantee that
the person trying to gain access is authorized. However,
these systems are expensive, may require more time to
verify identity than other systems, and must be calibrated
carefully to reduce the number of authorized individuals
who are denied access.
No matter how advanced the security system, the im-
portance of the human element in security for monitoring
and response cannot be overstated. When considering im-
plementing these measures, healthcare facilities should
choose equipment that is appropriate to the threats iden-
tified and that can be operated effectively by security
personnel.
Notes
1. Sarratt WG. Security from the outside in. J Healthc Prot
Manage 1997-98 Winter;14(1):36-47.
2. Cisky v. Longs Peak Association, et al., 84 CV 5668 (Colo.
Dist. Ct.). Cited in: Colling RL. Hospital and healthcare se-
curity. 4th ed. Boston: Butterworth-Heinemann;
2001:377-8.
3. Honey G. Electronic access control. Oxford: Butterworth-
Heinemann; 2000.
4. Ibid.
v
Recognizing Potentially Violent Individuals
Distraught Family Members and Friends
Uncertainty, grief, and frustration experienced by pa-
tients’ family members and friends can translate to
physical or verbal aggression toward staff members. A
survey of nurses in a 770-bed Florida hospital found
that the most common causes of assault by family
members and visitors were anger related to enforce-
ment of hospital policies, to the patient’s condition or
situation, to long wait times, and to the healthcare sys-
tem in general.20 Healthcare workers and staff mem-
bers should not feel like they are on their own in
mitigating this problem.
A Chicago-area hospital established a formal “family
triage team” after receiving several reports of encoun-
ters with volatile family members—as well as reports
that nurses perceived little support from management
5
Healthcare Risk Control Safety and Security 3

Healthcare workers may find themselves on the receiving end of verbal or physical assaults by patients’ family members, who are fueled by
grief, anxiety, and feelings of helplessness. This violence de-escalation tool, developed by Advocate Lutheran General Hospital in Park Ridge,
Illinois, gives caregivers a framework for responding to distraught family members and provides guidance on when security, management,
and support staff should be notified.

Table. When Hostilities Rise, Don’t Go It Alone

Intensity/Intervention Behavior Action

Level I No unusual behaviors; family appears to be coping Provide usual family support, education, and informa-
Prevention appropriately. tion; request for supportive counseling for patient or
family within scope of usual services.

Level II Family has not identified a spokesperson despite Notify charge nurse, care coordinator, other managers,
De-escalation requests to do so. and physician. These individuals, along with the RN,
Information not shared accurately among family coordinate which support services to provide—family
members; confusion about patient’s medical status conference, patient care conference, social work con-
sult, Family Triage Team meeting, care coordinator
Advance directives/power of attorney not addressed
follow-up, or psych support.
despite request/direction from medical staff
Hospital system contributes to family stress—limited
communication, staff not immediately available to
family members.

Level III Family member has alcohol on breath.
Consultation Excessive worry expressed by family members
Verbal conflict observed among family members or
between family and staff; family declines to be in-
volved or appears overwhelmed and not able to
participate in decision-making.
Family requests outside opinions.
Family threatens to sue.
Discuss with physician. Notify charge nurse, care coor-
dinator, and manager as soon as possible.
Request a consultation with most appropriate group:
psychiatry, pastoral care, ethics, or social work. Facili-
tate follow-up with Family Triage Team or care
coordinator.

Level IV Physical aggression observed either within family
Urgent Response or toward patient or staff
Staff feels safety is threatened.
Aggressive behavior observed—raised voice, threat-
ening gestures, invasion of personal space, verbal
threats
Individual interferes with nursing care or refuses to
leave room when requested.
Notify charge nurse, security, nursing supervisor, phy-
sician, and managers right away. Request immediate
response.
Use de-escalation techniques to establish authority
and safety; request STAT evaluation for removal,
arrest, or psychiatric admission.

Adapted from: Schmidt, M.F., & Lacey, R.F. (2002, Jan. 16). Caring for families intensively. Presentation at Lutheran General Hospital, Park
Ridge, IL.

Source: Barthel VA. We stop aggression as soon as it starts. RN 2004 Oct;67(10):33-6.

Reprinted with permission from Virginia A. Barthel, M.A., R.N., CHE, vice president of clinical operations, Advocate Lutheran General Hospital,
Park Ridge, Illinois.

during these difficult situations.21 The goal of the
team, which included the directors of the critical care
and behavioral health units, intensive care unit (ICU)
managers, care coordinators, clinical psychologists,
and social workers from the ICU, was to intervene in
potentially violent situations before a more dramatic
response becomes necessary. The team developed a
four-tiered response tool to guide ICU staff on de-
escalation methods to use based on the level of agita-
tion or aggression shown by family members; the tool
is reprinted in the table titled “When Hostilities Rise,
Don’t Go It Alone.” The ICU staff received education
from clinical psychologists on identifying early warn-
ing signs of stress, such as rapid pacing, excessive
fidgeting, and shouting, in family members. The pro-
gram has received positive feedback from staff, the
hospital says.22
Patients and Employees Who Attract Violence
Patients who present to hospital emergency depart-
ments (EDs) may be there because they have been in-
jured by their spouse or partner, who may follow the
patient to the healthcare facility and cause a violent
episode. Identifying a victim of domestic abuse can be
challenging due to wide variation in clinical presenta-
tion. However, screening questions on domestic abuse
can be easily incorporated into the history-taking

6 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2005
Safety and Security 3
process by including them in discussion of the pa-
tient’s medical history, social history, or history of
present illness, whichever seems most appropriate and
is most comfortable for the provider. (Additional con-
siderations for ED violence prevention are described
later in this Risk Analysis.)
Healthcare workers may also be victims of domestic
violence and could be targeted at work by their abus-
ers. Supervisors should be trained to detect warning
signs that employees are experiencing domestic violence
and to refer employees to the employee assistance pro-
gram (EAP). See the Risk Analysis titled “Domestic
Violence” in Supplement A of the HRC System for more
information on this topic.
Patients or healthcare workers may become victims
of stalking. Patients are particularly vulnerable while
in a hospital bed. Patients should be encouraged to
report threats against them during the intake process
(e.g., show protection orders). Patients who report
being threatened or stalked should be placed in a
room that can be easily and constantly monitored. Of
course, this type of information must be treated as
confidential. Only with assurance of confidentiality
will patients or healthcare workers come forward with
this information.
The following seven actions have been recom-
mended if an employee is being threatened or stalked:
(1) Relocate his or her workstation. (2) If the threat is
acute, give the employee time off. (3) Provide photo-
graphs of stalkers to receptionists and security officers.
(4) Encourage law enforcement to enforce restraining
orders. (5) Place silent alarms at the employee’s work-
station.23 (6) Deploy security cameras near entrances to
the employee’s workstation. (7) Provide protective
services.24
Healthcare Workers as Perpetrators of
Violence
Healthcare facilities must exercise precautions to mini-
mize the risk of violent behavior from staff members.
The stressful environment of a healthcare facility can
increase the chance that individuals who usually do
not demonstrate violent tendencies will act violently.
Drug and alcohol abuse (for which many healthcare
workers may be at risk due to the stressful nature of
their occupation) exacerbates the risk. However, em-
ployees generally do not just “snap”—red flags usu-
ally appear first. Supervisors and employees should
be advised of the following warning signs:25,26,27
· A new and obsessive fascination with weapons
and/or violence
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
· Behavior that includes the following:
— Making veiled or overt threats of harm
— Intimidating others
— Expressing an unrequited (usually romantic) ob-
session with one person
— Blaming or dehumanizing others
— Withdrawing or becoming isolated
— Holding a grudge
— Demonstrating attendance, behavior, or perfor-
mance problems
· Expression of extreme desperation over financial,
family, or personal problems
· Breakdown of social relationships between employees
· Association with hate or extremist groups
· Drastic changes in belief system (e.g., believing that
violence can be justified)
· Theft or sabotage of projects or equipment
· Perception that “everyone is against me”
· Expression of moral righteousness that the
healthcare facility is not following its own policies
and procedures
If an employee exhibits any of these indicators of
potentially violent tendencies, staff members should
inform their supervisor. The supervisor should main-
tain confidentiality by first talking to HR department
staff or someone from the EAP. However, if the health-
care worker is creating a hostile work environment—
or if the reported behavior poses an immediate threat
to patient or staff safety—the behavior must be
addressed immediately.
A 2003 survey conducted by the American Associa-
tion of Occupational Health Nurses found that U.S.
workers are largely unaware of the warning signs of
workplace violence. A majority of survey respondents
did not recognize many of the red flags, such as mood
changes, personal hardships, and mental health issues
(e.g., depression), that signal a possible violent epi-
sode. The survey also revealed a disparity in how men
and women perceive violent behaviors—for example,
94% of women characterized stalking as workplace
violence, while only 73% of men considered this a vio-
lent behavior.28
Supervisors and employees should be educated to
recognize warning signs. Supervisors should refer em-
ployees to the facility’s EAP when appropriate. As
discussed above, healthcare workers and staff mem-
bers not normally prone to violence may unpredict-
ably lash out due to workplace or personal stressors.
7
Healthcare Risk Control
EAPs, often overseen by the HR department or the
employee health and safety department, can contrib-
ute to minimizing the risk of this type of violence. Em-
ployees should be aware of the existence of the EAP,
which should offer individual counseling or family
counseling.29
Disciplined or Fired Employees
A healthcare worker who is fired or disciplined could
potentially perpetrate retaliatory violence, especially
if any of the above indicators are exhibited before the
firing or disciplinary action. Risk managers should
ensure that supervisors give all employees notice of
rules and the corresponding disciplinary actions for
breaking those rules. This forewarning can prevent
employees from feeling singled out if disciplined. If an
incident that may require discipline or termination oc-
curs, investigate the situation to get the employee’s
side of the story; ensure consistence in the treatment
of all employees. Supervisors should be provided with
training in how to discipline and fire employees with-
out triggering a violent outburst.30
Healthcare facilities may consider providing job
counseling through the EAP for terminated or laid-off
workers. This shows that the facility cares, and it may
reduce hostility levels. When potentially violent or
highly disgruntled employees must be terminated,
staff may prevent a violent response by making eye
contact, by allowing the employee to communicate his
or her feelings, by listening attentively and paraphras-
ing what is being said, by empathizing but not apolo-
gizing, and by always asking if there are further
questions before closing the meeting.31 After the em-
ployee’s termination, a security officer should be
available to escort the employee back to his or her
desk and then to the door of the building. Identifica-
tion cards and badges should be returned, and
computer identification passwords should be deleted
from the system.
Employees Who Harm Patients
A rarer—although more sinister—manifestation of
violence by healthcare workers is purposeful patient
harm. Most healthcare workers are dedicated, caring
individuals; however, no healthcare facility is immune
to “bad apples.” Enforcing stringent background
check procedures is the key preventive measure. One
of the most accurate predictors of harmful or violent
behavior is a history of violence or implication in sus-
picious patient injury or death. If an event involving
employee violence does occur, it is important, from a
8 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Safety and Security 3
liability standpoint, for the healthcare facility to be
able to show that it did everything in its power to
screen out employees with a violent past. (For more
information on conducting employee background
checks, see the Risk Analysis titled “Criminal Back-
ground Checks” in Volume 3 of the HRC System.)
However, background checks are not foolproof
safeguards against hiring employees who may turn vi-
olent. Risk managers must work with supervisors to
ensure they treat employee reports of suspicious be-
havior seriously, investigate reports thoroughly, and
never react negatively toward the reporting employee.
In alarming cases, healthcare workers continued to
maliciously harm patients because warning signs went
unnoticed or were ignored by other employees, super-
visors, and healthcare facility administration.
In 2001, Kristin Gilbert, a nurse at a Massachusetts
Veterans Administration hospital, was convicted of
murdering several patients at the facility by adminis-
tering lethal doses of epinephrine and potassium.
Despite the fact that the rates of codes, medical emer-
gencies, and patient deaths soared on Gilbert’s unit
and that these events always occurred during her
shift, she was able to continue her killing spree for
several years.32
In 2003, Charles Cullen admitted to killing dozens
of patients by lethal injection during his career as a
nurse at hospitals and nursing homes in Pennsylvania
and New Jersey. According to coverage in the New
York Times, Cullen’s employment history and personal
life raised a series of red flags indicating that he could
be harming patients, but these warning signs were
hidden from employers because of “systemic failures
and . . . gaping holes in hospital and government sys-
tems for weeding out people who harm patients.”33
Observers of the case, including prosecutors in New
Jersey, have argued that Cullen’s employers’ reluc-
tance to make adverse reports when prospective em-
ployers called for recommendations contributed to
Cullen’s ability to evade detection for so long. Cullen’s
case prompted new legislation in New Jersey and
Pennsylvania affording greater liability protection to
healthcare facilities that report employee misconduct.
At seven of the hospitals that had employed him,
Cullen was under investigation, had been fired, or
had been forced to resign, yet not one of those facili-
ties provided a negative reference for him.34 Investiga-
tion yielded records showing that Cullen ordered the
medication digoxin at “medically alarming” rates, that
he was caught stockpiling lethal medications at one
facility and was then allowed to resign, and that he
September 2005
Safety and Security 3
frequently violated several nursing standards. Cullen
stated that flawed security and hiring procedures al-
lowed him to continue to murder patients at facility
after facility.35 As of this writing, several of Cullen’s
former places of employment are embroiled in law-
suits related to his crimes.36
Recovery rooms and other areas of a healthcare fa-
cility where patients may be found alone, vulnerable,
unconscious, or unmonitored are likelier than other
areas to be the scene of crimes against patients. Sev-
eral years ago, a Florida hospital was sued by 41 pa-
tients who were allegedly sexually assaulted by a
male nurse who usually worked alone in the recovery
room.37 Having at least two staff members present at
all times in recovery rooms can help guard against
intentional patient harm.
Although rare, occurrences in which healthcare
workers purposely harm patients, whether by assault-
ing them or by providing inappropriate medical treat-
ment, can be extremely damaging to a healthcare
facility’s reputation. Such occurrences can instantly
destroy the trust of patients and the community, re-
quiring a significant length of time for the facility to
rebuild its image. As stated previously in this Risk
Analysis, performing thorough reference and criminal
background checks is the first step in protecting pa-
tients and the facility against this risk; the next steps
include vigilantly managing response to complaints or
observances of suspicious behavior and enforcing the
zero-tolerance policy.
Violence Management Training
Some violence management training should be pro-
vided to all staff at orientation, even if there is a low
risk of violence. This training should include the
following:
· What to do if a violent event occurs—for example:
— How to report events
— How to respond to alarms
— What kind of code to call
— What assistance is available if an event occurs
· What causes and how to recognize escalating vio-
lent behavior
· What to do if outsiders are seen in the “wrong” ar-
eas of the facility
· What to do if a colleague’s behavior suddenly
changes
· How to prevent or defuse volatile situations
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
· How to interact with hostile individuals or
colleagues
· Why it is important to inform supervisors and HR
of any problem with domestic parties
· How and where to get medical treatment and psy-
chological counseling after an event
Supervisors and security officers must be trained to
recognize potentially violent situations before they oc-
cur. They should also be able to recognize physical
conditions or procedures that increase violence risks
in order to make changes before an event occurs. The
Risk Analysis titled “Patient Violence” in Supplement
A of the HRC System contains detailed information on
violence de-escalation training. See “Managing a Hos-
tage Situation” in this Risk Analysis for tips on
training for a hostage event.
Conducting a Violence Audit
First Step: Records Review
This process should include not only reviewing past
documentation of violent acts within the facility, but
also collecting statistics on violent gang activity, drug
abuse, and other such issues in the community. Re-
cords include existing documentation, such as the
OSHA log, union information, incident reports, Work-
ers’ Compensation or other insurance reports, minutes
from safety and risk management meetings, security
reports, and suggestions from healthcare workers. A
records-review checklist accompanies the Risk Analy-
sis titled “Patient Violence” in Volume 4 of the HRC
System. During the records-review process, facilities
can also find out if and when healthcare workers are
bypassing the internal incident-reporting procedure
and going directly to the police (e.g., vandalism on
healthcare workers’ cars in parking lots is often not
reported internally).
Ask the local police department to provide a com-
munity crime profile, which should include the num-
ber and types of criminal offenses committed in the
vicinity of the facility and the time(s) of day when in-
cidence of violent crime is the highest. Subscribing to
a service that provides a comprehensive breakdown of
local crime statistics is a popular method for garnering
this information. Consult local shop owners and other
area healthcare facilities about the amount of violence
in and around their establishments. Read national pa-
pers for trends in violent crime, or call the U.S. Bureau
of Labor Statistics to identify trends in comparable
(continued on page 11)
9
Healthcare Risk Control
Managing Hostage Situations
It began as an argument between a man and woman whose in-
fant was a patient in the pediatric ward of a Florida hospital.
The situation escalated alarmingly enough that a nurse stepped
in to remove the couple’s one-month-old son from the second-
story room while other staff members called security. Eventually,
the man barricaded his girlfriend in the room and allegedly
shattered the window, prompting hospital officials to relocate
patients and staff from the first three floors of that wing to other
parts of the hospital. The six-hour standoff ended with only mi-
nor injuries to the couple when the police department’s special
response team broke into the room and gained control of the
situation.
The potential for a healthcare facility to experience a
hostage situation may be deemed minimal. However,
when one considers the facts in this real-life vignette,
such a scenario does not seem so far removed. Further-
more, the frequency with which firearms are involved in
workplace violence rose throughout the last decade.
Law-enforcement experts say that the probability of a
hostage situation occurring increases dramatically with
the presence of firearms.1
Hostage situations may be planned in advance—for
instance, as a vengeful act by a fired or disciplined em-
ployee. Or, as in the example above, they may be the
culmination of an escalating violent dispute. Areas that
may be more vulnerable to hostage situations include the
emergency department (ED), the pharmacy, obstetrics,
pediatrics, and the finance divisions of patient accounts/
billing. Strengthening access-control measures in the
healthcare facility and to these areas in particular is a key
proactive measure in preventing hostage situations. Other
proactive interventions include installing closed-circuit
television cameras, silent emergency-notification devices,
and bullet-proof glass in high-risk areas. Facilities in
high-crime areas might consider installing a metal detec-
tor in the ED.2
A healthcare facility’s violence-prevention program
should include a plan for responding to hostage situa-
tions. A management plan for hostage situations might
include the following procedures for the healthcare facil-
ity and its security department:
· Notify the security department and the local police
department immediately, as well as key management
and administrative personnel.
· Relocate patients as necessary.
· Establish a protective perimeter around the scene and
a temporary command post to collect information as
the event unfolds.
· Document as much information as possible, such as
the number of perpetrators and their mental condition,
10 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Safety and Security 3
the number and condition of hostages, and the num-
ber and types of weapons involved.
· Gather witnesses and keep them separate from one an-
other so that law-enforcement officials can interview them.
· When law enforcement arrives, provide a briefing of
the situation, as well as maps of the affected area and
witness information.
· As soon as law-enforcement professionals replace fa-
cility security department personnel, focus on crowd
control, as well as media and conference room posts,
and provide assistance to police when needed.3
Providing staff with training and education on hostage
situations is one of the most important measures in re-
ducing fallout should such an event occur. Just as with
fire drills and disaster drills, conducting hostage-situation
drills can increase staff preparedness. Promote awareness
of the following survival tips for healthcare workers and
others who find themselves the victims of a hostage
situation:
· Be aware that the first 15 to 45 minutes of a hostage
situation are usually the most dangerous.
· Try to be patient, and remember that negotiations can
take hours.
· Do not attempt to negotiate with the perpetrator.
· Cooperate with the perpetrator.
· Treat the perpetrator with respect.
· Do not speak unless specifically addressed by the
perpetrator, and do not volunteer information or
suggestions.
· Do not make promises to the perpetrator that cannot
be delivered.
· Beware that a failed escape attempt can be extremely
dangerous for all hostages.
· Be prepared to take cover on the floor when rescuers
arrive.4
Notes
1. Lightfoot S. Workplace violence: hostage situations in
the healthcare setting. J Healthc Prot Manage 1998 Sum-
mer;14(2):32-44.
2. Ibid.
3. Ibid.
4. Ibid.
v
September 2005
Safety and Security 3
(continued from page 9)
locations with similar populations (e.g., an inner-city
facility in New York City may wish to compare crime
statistics with similarly located facilities in Chicago).
To get a more complete list of possible risks, con-
sider distributing a questionnaire or publishing a note
in the facility newsletter asking healthcare workers
(and volunteers, etc.) to identify specific violence risks
or concerns (e.g., while there may be no history of as-
saults in the parking lots, healthcare workers may be
afraid to walk there after dark). Consult with the HR
department, the EAP, or supervisors about how to
best do this without alarming healthcare workers.
Otherwise, healthcare workers may mistakenly as-
sume a serious violence problem exists in the facility.
Second Step: Violence Assessment Walk-Through
A violence walk-through should focus on any physical
areas identified during the records review as high risk,
as well as areas of healthcare facilities notorious for
violent incidents, such as the ED, parking lots, and psy-
chiatric units. The assessment team should include
frontline healthcare workers with nurse representatives
from each unit as well as facility safety and security
professionals.38 As stated previously, any deficiencies
documented during the walk-through must be ad-
dressed immediately or the facility risks being held lia-
ble under the theory of foreseeable risk should violence
occur. During the walk-through, healthcare workers
may be questioned about relevant details. The team
should try to assess issues such as prevailing style of
management, areas of excess stress, and ways people
organize their duties. Attention should be given to is-
sues not addressed during the security walk-through,
such as the following:
· Are windows and doors secure?
· Are security guards or other individuals trained to
respond to an emergency violence code?
· Is aggressiveness de-escalation training being
performed?
· Are patients’ valuables stored in a secure place?
· Are staffing levels, especially during meal times,
visiting hours, and “trauma season,” adequate?
· Is access to floors being monitored?
· Is equipment secure (e.g., sharps are properly
stored)?
· Are rooms laid out to prevent entrapment (e.g., ex-
amination room exits are unobstructed)?
· Are bulletproof vests available or necessary?
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
· Are there mechanisms in place to relieve over-
crowding of high-traffic areas?
· Is lighting adequate?
· Are staff lounges locked?
· Are private areas available for distraught family
members?
· Are panic buttons located at nursing stations and
registration desks?
· Are in-house emergency call numbers posted for all
staff to summon help?
· Are all access areas monitored or controlled?
· Is appropriate signage in place and legible?
· Are monitoring devices in place and operable?
During the walk-through, ask healthcare workers the
following questions:
· Are you ever totally alone on the unit?
· Are you ever out of hearing or sight of other
healthcare workers?
· Is there anything about your physical work envi-
ronment that could contribute to an assault?
· Do you know the emergency codes and how to re-
spond to violence?
· Have you had any violence-related training?
The facility should be surveyed during all shifts
and situations (e.g., holidays, emergencies). On holi-
days and during third shift, there may be staff short-
ages that make the facility more vulnerable to
violence. During disasters, people are usually so in-
volved with response efforts that they may forget pro-
cedures that protect against violence.
HRC System members can use Self-Assessment
Questionnaire 28, “Violence Prevention,” in Volume 1
to identify strengths and weaknesses of the facility’s
violence-prevention program. Appendix A to OSHA’s
workplace-violence guidelines (http://www.osha.gov/
Publications/osha3148.pdf) includes violence-prevention
checklists that can help healthcare facilities target
areas needing improvement.
Special Considerations for High-Risk Areas
Just as the risk of violence varies from healthcare facil-
ity to healthcare facility, it also fluctuates throughout
an individual organization, as some areas or depart-
ments are more vulnerable to violence than others.
During the physical walk-through, keep in mind the
following considerations regarding high-risk areas:
ED. Several factors predispose the ED to violence. As
the main route of public access into the facility, EDs
11
Healthcare Risk Control
are often understaffed and overcrowded, and they
may be populated by patients who are victims of
violence (and who may be followed to the ED by their
attacker). An injured gang member in the ED could
attract members of rival gangs. Healthcare facilities in
areas prone to gang activity should consider inviting
local police officers to conduct in-services for ED staff
so they can more easily identify gang members by
dress or paraphernalia and have higher awareness of
the characteristics of local gangs.39
A study of Michigan ED physicians found that vio-
lence against ED physicians is prevalent. Patients’
family members or friends were the attackers in 10%
of cases reported. Notably, the perceived threat of vio-
lence drove some responding physicians to obtain a
knife, gun, club, or Mace for protection.40 The use of
weapons by individuals who have not been trained in
proper use increases the chance that a violent situation
will end in injury or fatality. Only 27% of responding
physicians reported that security officers were assigned
to the ED in their hospitals.
Perform the following steps during an ED walk-
through:
· Assess the physical design of the ED to see if there
are barriers separating patients and visitors from
treatment areas and if the ED can be secured from
the rest of the facility.
· Make sure the ED has panic buttons, alarms, and
emergency code procedures.
· Find out how ED events are processed.
· Ensure that staffing levels (clinical and security
personnel) are adequate during periods of high use
(e.g., Friday nights for inner-city facilities in areas
with a history of gang or drug activity) noted dur-
ing the records review. Check to see that vending
machines, magazines, and telephones are located
in the ED to make clients who are waiting more
comfortable.
· Check to see if the receptionist and other personnel
exhibit sensitivity to the patients and their visitors
(e.g., making eye contact, responding calmly and
inoffensively to queries).
Facilities in high-crime areas might consider install-
ing metal detectors at ED entrances. A Detroit hospital
that installed metal detectors supplemented by hand-
held units prevented the entry of 33 handguns, 1,324
knives, and 97 disabling sprays during a six-month
period.41 However, metal detectors can be expensive
to maintain and can raise liability issues. All entrants
must be scanned; otherwise, the facility could be liable
12 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Safety and Security 3
for discriminatory scanning or for failing to detect a
weapon later used in a violent event. A security offi-
cer should be posted next to the metal detector.
A policy should be established for handling weap-
ons found during scanning. (Refer to the HRC Risk
Analysis titled “Patient Violence” for a sample policy
on possession of firearms.) This policy should include
methods for dealing with people who refuse to sur-
render weapons. Attempting to take a weapon from
someone unwilling to surrender it can provoke vio-
lence. Weapons that are surrendered should be kept in
a locked, secure place and, depending on facility pol-
icy, may be returned when the person leaves. Keep a
weapon-release form, along with signatures of people
who surrender and receive weapons. Consult legal
counsel to determine whether permits should be veri-
fied before surrendered weapons are returned. Health-
care workers responsible for impounding and storing
weapons should be familiar with firearm safety.
Intensive care unit (ICU). Because the ICU cares for the
most seriously ill patients, visitors to this area are
likely to be extremely distraught, stressed, and de-
manding of staff attention, which may often be in
short supply. This combination can lead to verbal ag-
gression toward staff and escalate into physical as-
sault, especially if staff are not properly trained in
responding to distraught visitors (see the table titled
“When Hostilities Rise, Don’t Go It Alone”).
Neonatal intensive care unit/pediatric intensive care unit.
Divorced or estranged partners may fight for custody
of their children in nurseries or on pediatric floors.
Concerned parents may also become violent after find-
ing out that their child has an incurable disease, while
waiting for test results, or while waiting to talk to a
physician. Policies on how to deal with estranged par-
ents should be in place, and there should be proce-
dures for proving that abuse-protection and custody
orders are valid.
HR department. While HR offices should not be cen-
trally located, they should also not be in remote or
unmonitored areas of the facility, where HR personnel
would be vulnerable to verbal or even physical as-
saults by terminated or disciplined employees. HR
should be located in an area accessible to all employ-
ees but close to the facility’s main entrances. This way,
job applicants will be able to easily locate HR and will
not have any reason to wander around the building.
Parking lots and other exterior areas. Several factors can
contribute to a parking area becoming the scene of vi-
olence—parking areas may be dark, may offer many
hiding places, and may be deserted at certain hours.
September 2005
Safety and Security 3
Check parking lots during high- and low-use periods.
Observe people’s behavior; no one should wander the
lot aimlessly. Do the following to reduce the risk of vi-
olence in parking lots and other outdoor areas on the
facility campus:
· Check for risks such as overgrown shrubbery, inad-
equate lighting, and columns or other structures
that may obstruct vision or create shadows.
· Ensure the presence of easily accessible call boxes
and working alarm buttons. Check the response
time when a call box is activated.
· Use light-colored paint on garage walls.
· Designate a special place for third-shift employees
to park (closer to the building and in a more highly
monitored area).
· Have any new structures designed to eliminate
dark corners and interior support columns.
· Encourage a buddy system when people enter the
lot at night, and encourage staff and patients to be
cautious, carry handbags under their arms, and
look into cars before entering.
· Use signage to dissuade trespassing and loitering
on healthcare facility property, especially in park-
ing lots and garages.
Adequate lighting is important in other outside ar-
eas of the healthcare facility campus. A 2002 study
on reducing workplace homicide found that bright
exterior lighting was the environmental factor most
strongly associated with reducing the risk of homi-
cide.42 Lighting should be uniformly distributed with
attention to preventing glare, surface reflection, and
interaction with electronic surveillance systems. Lights
that are too far apart or are obstructed by large trees
or structures can create shadows that conceal intrud-
ers. An individual leaving a building at night should
never have to pass from a comfortably lit space into
either a very bright or a very dark space.
Home health services. Home healthcare workers who of-
ten must enter homes alone are also particularly vul-
nerable to violence. A buddy system (i.e., the worker
calls a buddy on arrival, departure, and safe arrival at
the next job or home) should be used when employees
go into high-risk areas. In these areas, escorts—either
police officers or properly trained security officers—
should be provided for home healthcare workers. A
means of communication with police or the facility
should be provided to employees, especially those
who travel alone.
September 2005 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility.
Healthcare Risk Control
In the Wake of a Violent Event
Despite a healthcare facility’s best efforts, violent
events are bound to occur. After victims have been
cared for and the area has been cleaned (blood, bro-
ken glass, and sharp objects removed), disseminate
information to appropriate individuals on what hap-
pened, what actions will be taken against perpetrators,
and what steps the facility will take to prevent a re-
currence. Provide periodic progress updates.
Procedures should be in place to guide the release
of information to media representatives. The more vi-
olent the event, the more the media will be attracted.
See the Risk Analysis titled “Media Relations” in Vol-
ume 2 of the HRC System for more information on this
topic.
Counseling should be available to employees who
are victims of, involved in, or witnesses to violent
events. Employees may fear returning to work or even
suffer posttraumatic stress syndrome; it may be bene-
ficial to allow victims to transfer to a different area of
the facility if desired. Certified employee assistance
professionals, psychologists, psychiatrists, clinical
nurse specialists, or social workers should provide
this counseling. The facility may also refer employees
to outside specialists for this need. Some employees
may prefer peer counseling or employee support
groups. It is imperative that employees involved in vi-
olent events, whether as victims or tangentially, feel
supported and never feel that they are being blamed.
Thorough documentation and investigation of the
violent episode can provide a bit of a silver lining to
an otherwise negative situation. By identifying con-
tributing factors—inadequate security, failure to inves-
tigate complaints of suspicious behavior, physical
features of the facility—the facility can develop cont-
rols to prevent a recurrence.
ACTION RECOMMENDATIONS
· Work with the security department to audit your
facility’s risk of violence. Evaluate environmental
and administrative controls throughout the campus,
review records and statistics of crime rates in the
area surrounding the healthcare facility, and survey
employees on their perceptions of risk.
· Use the Self-Assessment Questionnaire titled “Vio-
lence Prevention” in Volume 1 of the HRC System
to identify strengths and weaknesses and make
improvements to the facility’s violence-prevention
program.
13
Healthcare Risk Control Safety and Security 3

Resource List
American Association of Occupational Health Nurses National Institute for Occupational Safety and Health
(AAOHN) 1600 Clifton Road
Suite 100 Atlanta, GA 30333
2920 Brandywine Road (800) 356-4674
Atlanta, GA 30341 http://www.cdc.gov/niosh
(770) 455-7757 · Violence: occupational hazards in hospitals [guidance
http://www.aaohn.org document online]. 2002 Apr [cited 2005 Jun 10]. Avail-
· Violence prevention . . . at work: an AAOHN survey able from Internet: http://www.cdc.gov/niosh/
[online]. 2003 [cited 2005 Jul 6]. Available from 2002-101.html.
Internet: http://www.aaohn.org/press_room/
workplace_violence_survey_findings.cfm. Occupational Safety and Health Administration
200 Constitution Avenue NW
International Association for Healthcare Security & Washington, DC 20210
Safety (IAHSS) (800) 321-6742
PO Box 5038 http://www.osha.gov
Glendale Heights, IL 60139
(630) 871-9936 · Guidelines for preventing workplace violence for
http://www.iahss.org health care and social service workers. 2004.
· The 2003 IAHSS survey—crime in hospitals. J Healthc · Hospital eTool: workplace violence [online resource].
Prot ManageJ Healthc Prot Manage 2005 Win- [cited 2005 Jul 6]. Available from Internet: http://
ter;21(1):1-33. www.osha-slc.gov/SLTC/etools/hospital/hazards/
workplaceviolence/viol.html.
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) · Injury and illness record-keeping standard
One Renaissance Boulevard
Oakbrook Terrace, IL 60181 Additional listings can be found in ECRI’s Healthcare Stan-
(630) 792-5000 dards Directory, a comprehensive source of healthcare stan-
http://www.jcaho.org dards, guidelines, laws, and regulations. The Directory is
available from ECRI.
· Standard EC.2.1. In: Comprehensive accreditation manual
for hospitals. Oakbrook Terrace (IL): JCAHO; 2004. v

· Conduct thorough prescreening of job applicants, · Ensure that counseling programs for employees
and ensure that procedures for background checks who become victims of workplace crime or violence
of prospective employees and staff are in place. are in place.

· Encourage employees and other staff to report inci-
dents of violent activity or any perceived threats of
violence.
· Ensure compliance with OSHA’s requirements for
reporting workplace injuries on the OSHA Form
300 log.
· If the facility is in an area with a high rate of crime
and/or gang activity, consider taking extra security
precautions in the ED (e.g., installing metal detec-
tors, using police dogs).
· Collaborate with the HR department to ensure that
procedures for disciplining and firing employees
seek to minimize the chance of provoking a violent
reaction.
· Require appropriate staff members to undergo
training in responding to patient family members
who are agitated and potentially violent. Include
education on procedures for notifying supervisors
and security staff.
· Ensure that procedures for responding to incidents
of workplace violence (e.g., notifying department
managers or security, activating codes) are in place
and that employees receive instruction on these
procedures.
· Educate supervisors that all reports of suspicious
behavior or threats by another employee must be
treated seriously and thoroughly investigated. Train
supervisors to recognize when an employee may be
experiencing domestic violence.

14 ©2005 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2005
Safety and Security 3
· Work with the media relations department to deter-
mine procedures for release of information regard-
ing violent events that occur at the facility.
Notes
1. International Association for Healthcare Security & Safety.
The 2003 IAHSS survey—crime in hospitals. J Healthc Prot
Manage 2005 Winter;21(1):1-33.
2. Joint Commission on Accreditation of Healthcare Organi-
zations. Sentinel event trends: assault/rape/homicide
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28. American Association of Occupational Health Nurses.
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33. Pérez-PeZa R et al., supra note 15.
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35. Assad M. Cullen gives tips for stopping killings [online].
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36. Ibid.
37. 41 patients settle with hospital in ‘sedated’ sexual assault
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38. Occupational Safety and Health Administration, supra
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41. National Institute for Occupational Safety and Health,
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42. Loomis D, Marshall SW, Wolf S, et al. Effectiveness of
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