preventing violence in hospitals: applying the learnings ...€¦ · resulting in injury.1...
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HarmVictims were punched, slapped, kicked, pushed, thrown, bitten, spat at,
fondled, and/or struck with an item. In 63% of the assault events, staff
or patients experienced emotional distress, injury requiring treatment,
or temporary harm (Figure 1). Physical harm included pain, bruising,
swelling, abrasions, lacerations, bites, punctures, and head injuries.
a Based on Agency for Healthcare Research and Quality Harm Scale v.1.1.
Location Assaults by patients were most commonly reported in the emergency depart-
ment (Figure 2). Patient-on-patient assaults were common in emergency
department holding areas. Some assaults occurred during transport to or from
medical tests, during those tests, or in public areas when a staff member was
alone or it was difficult for him or her to obtain assistance.
Time Peaks in assaults occurred during mealtimes, when staffing levels may have
been lower (Figure 3).
Contributing FactorsCommon characteristics of assaultive patients and factors contributing to
violence are shown in Figure 4.
Preventing Violence in Hospitals: Applying the Learnings From Safety Data to Drive ChangeTammy Williams, MSN, RN, Project Manager, Patient Safety Research, UHC; Ellen Flynn, JD, MBA, RN, Patient Safety Officer, UHC; Marilyn Szekendi, PhD, RN, Director, Quality Research, UHC; Stephen Thomas, Data Analyst, UHC
Effective April 1, 2015, VHA, the national health care network of not-for-profit hospitals, and UHC, the alliance of the nation’s leading academic medical centers, merged to form the largest member-owned health care company in the country. The new entity is dedicated to leading health care innovation, creating knowledge, and fostering collaboration to help members thrive.
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IntroductionHealth care workers are at high risk of injury from on-the-job assaults and violent acts. Nurses and patient care assistants suffer the most nonfatal assaults
resulting in injury.1 Emergency department nurses experience physical assaults at the highest rate of all nurses.2-4 Violence in the workplace can result in
employee fear and low morale, stress symptoms, and declines in productivity, job satisfaction, and staff retention.5,6
MethodsThe UHC Safety Intelligence® Patient Safety Organization conducted a retrospective review of event reports on assaults by patients in the hospital setting from
2011 to 2014 to identify common factors and opportunities for prevention. Data were obtained from more than 60 participating organizations.
FindingsMore than 130 instances of patient violence directed at staff and other patients in the hospital setting were reported over the 3-year period.
References1. Guidelines for preventing workplace violence for health care and social service workers. Occupational Safety and Health Administration Web site. https://www.osha.gov/Publications/OSHA3148/osha3148.html. Accessed December 7, 2014.2. Crilly J, Chaboyer W, Creedy D. Violence towards emergency department nurses by patients. Accid Emerg Nurs. 2004;12(2):67-73. 3. Childers L. Danger on the job: nurses speak out against hospital violence. Minority Nurse. Summer 2011. http://www.minoritynurse.com/article/danger-job-nurses-speak-out-against-hospital-violence. Accessed December 7, 2014.4. Occupational Hazards in Hospitals: Violence. Cincinnati, OH: National Institute for Occupational Safety and Health; 2002. http://www.cdc.gov/niosh/docs/2002-101/pdfs/2002-101.pdf. Accessed December 5, 2014. 5. Survey of workplace violence prevention. Bureau of Labor Statistics Web site. http://www.bls.gov/iif/osh_wpvs.htm. Modified October 27, 2006. Accessed December 7, 2014.6. Taylor H. Patient violence against clinicians: managing the risk. Innov Clin Neurosci. 2013;10(3):40-42.
RecommendationsHospitals should review their safety procedures
and develop a comprehensive violence prevention
programs that includes1,4:
• A clear policy of zero tolerance for workplace
violence (including verbal and physical threats)
that is disseminated to all employees, patients,
and visitors and supported by management
and leadership.
• Procedures for reporting and responding to
episodes of violence, including offering and
encouraging counseling and debriefings
for employees involved in threatening or
violent situations.
• A workplace analysis to identify hazards,
conditions, operations, and situations that
can lead to violence and to determine the
effectiveness of existing security measures.
The analysis should include tracking and
analyzing reports of violence, conducting staff
surveys, and assessing workplace security.
• Tools and practices that are designed in
response to the findings of the workplace
analysis, such as:
– Alarm systems, handheld alarms, portable
phones or radios, and/or personal com-
munication badges
– Metal detectors, security cameras, and
safety-focused environmental design
– Computer alerts for patients with a history
of violence
• A formal violence prevention training program
that includes a review of the zero-tolerance
policy, risk factors, early warning signs, personal
safety strategies, techniques for de-escalating
patients, a standard response plan, and pro-
cedures for reporting and self-care after an
incident. Direct care workers, supervisors,
managers, and security personnel should all
receive training.
ConclusionThis analysis highlights the need for hospital
violence prevention programs that include
policies and processes to address the culture
of safety, staff training, an analysis of risks in
the workplace, and improvements aimed at
reducing identified risks.
0 10 20 30 40 50 60 70
Emergency department
Medical/surgical unit
Cardiac unit
Neurology/neurosurgical unit
Public areas
Pediatric unit
Treatment/test area
Other
Percentage of Events
Loca
tion
Type
0 5 10 15 20 25 30 35
Unsafe condition
Near miss
No harm evident
Emotional distress
Additional treatment
Temporary harm
Permanent harm or death
Percentage of Events
Exte
nt o
f Har
m
0 1 2 3 4 5 6 7 8 9
10
12:00
AM
2:00 A
M 4:0
0 AM
6:00 A
M 8:0
0 AM
10:00
AM
12:00
PM
2:00 P
M 4:0
0 PM
6:00 P
M 8:0
0 PM
10:00
PM
Perc
enta
ge o
f Eve
nts
Approximate Time of Event
Patient Factors• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neurological issues
Environmental Factors• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Process Factors• Assessment inadequate• Patient observation indequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
Patient Factors
Process Fa
ctor
s
PatientAssault
Environmental Factors
• Assessment inadequate• Patient observation inadequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors
PatientFactors
Process Factors
Environmental Factors
• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neuro- logical issues
• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Figure 1. Harma Resulting From Patient Assaults on Staff and Other Patients
0 10 20 30 40 50 60 70
Emergency department
Medical/surgical unit
Cardiac unit
Neurology/neurosurgical unit
Public areas
Pediatric unit
Treatment/test area
Other
Percentage of Events
Loca
tion
Type
0 5 10 15 20 25 30 35
Unsafe condition
Near miss
No harm evident
Emotional distress
Additional treatment
Temporary harm
Permanent harm or death
Percentage of Events
Exte
nt o
f Har
m
0 1 2 3 4 5 6 7 8 9
10
12:00
AM
2:00 A
M 4:0
0 AM
6:00 A
M 8:0
0 AM
10:00
AM
12:00
PM
2:00 P
M 4:0
0 PM
6:00 P
M 8:0
0 PM
10:00
PM
Perc
enta
ge o
f Eve
nts
Approximate Time of Event
Patient Factors• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neurological issues
Environmental Factors• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Process Factors• Assessment inadequate• Patient observation indequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
Patient Factors
Process Fa
ctor
s
PatientAssault
Environmental Factors
• Assessment inadequate• Patient observation inadequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors
PatientFactors
Process Factors
Environmental Factors
• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neuro- logical issues
• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Figure 2. Patient Assaults by Location
0 10 20 30 40 50 60 70
Emergency department
Medical/surgical unit
Cardiac unit
Neurology/neurosurgical unit
Public areas
Pediatric unit
Treatment/test area
Other
Percentage of Events
Loca
tion
Type
0 5 10 15 20 25 30 35
Unsafe condition
Near miss
No harm evident
Emotional distress
Additional treatment
Temporary harm
Permanent harm or death
Percentage of Events
Exte
nt o
f Har
m
0 1 2 3 4 5 6 7 8 9
10
12:00
AM
2:00 A
M 4:0
0 AM
6:00 A
M 8:0
0 AM
10:00
AM
12:00
PM
2:00 P
M 4:0
0 PM
6:00 P
M 8:0
0 PM
10:00
PM
Perc
enta
ge o
f Eve
nts
Approximate Time of Event
Patient Factors• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neurological issues
Environmental Factors• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Process Factors• Assessment inadequate• Patient observation indequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
Patient Factors
Process Fa
ctor
s
PatientAssault
Environmental Factors
• Assessment inadequate• Patient observation inadequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors
PatientFactors
Process Factors
Environmental Factors
• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neuro- logical issues
• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Figure 3. Patient Assaults by Time
Figure 4. Factors Contributing to Patient Assaults
0 10 20 30 40 50 60 70
Emergency department
Medical/surgical unit
Cardiac unit
Neurology/neurosurgical unit
Public areas
Pediatric unit
Treatment/test area
Other
Percentage of Events
Loca
tion
Type
0 5 10 15 20 25 30 35
Unsafe condition
Near miss
No harm evident
Emotional distress
Additional treatment
Temporary harm
Permanent harm or death
Percentage of Events
Exte
nt o
f Har
m
0 1 2 3 4 5 6 7 8 9
10
12:00
AM
2:00 A
M 4:0
0 AM
6:00 A
M 8:0
0 AM
10:00
AM
12:00
PM
2:00 P
M 4:0
0 PM
6:00 P
M 8:0
0 PM
10:00
PM
Perc
enta
ge o
f Eve
nts
Approximate Time of Event
Patient Factors• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neurological issues
Environmental Factors• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting
Process Factors• Assessment inadequate• Patient observation indequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
Patient Factors
Process Fa
ctor
s
PatientAssault
Environmental Factors
• Assessment inadequate• Patient observation inadequate• Warning signs ignored• Medication not ordered• Failure in communication
Staff Factors
PatientFactors
Process Factors
Environmental Factors
• Inadequate staffing• Increased staff workload • Inadequate training• Inadequate assistance • Assistance not requested
• Noncompliance, agitation, hostility• History of psychiatric issues• History of violence• Use of alcohol or other substances• Dementia, confusion, neuro- logical issues
• Lack of a safety culture• Overcrowding and noise• Patients in emergency department holding areas• Unavailability of beds/services• Inappropriate setting