HealthManagement, Volume 17 - Issue 5, 2017

Healthcare risk, quality & safety guidance

Healthcare risk, quality & safety guidance
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Violence in healthcare facilities


In the below summary, ECRI discusses violence in healthcare covering risk factors, assessment of objective indicators, consequences, and strategies for prevention.


Executive summary


Violence is much more common in healthcare than in other industries, and although many violent events in healthcare are perpetrated by patients, a notable percentage are not.


Individuals other than patients who may cause violence in healt hcare set tings include family members of patients and other visitors, employees, and criminals. Many factors contribute to violence in healthcare: patients and their loved ones are often vulnerable and, at times, distraught, healthcare workers must function in typically stressful environments, there is 24-hour access to the hospital setting, and the presence of drugs can make healthcare settings attractive targets.


Violence in healthcare may take a variety of forms, ranging from verbal aggression to physical assault, including the use of deadly weapons against physicians, other workers, and patients. It is therefore associated with a variety of risks for patient and worker safety as well as organisational liability. In addition to physical harm, individuals who experience or witness violence in the healthcare workplace are at risk for emotional consequences that can lead to time away from work, burnout, job dissatisfaction, and decreased productivity.


These and other consequences compromise both worker and patient safety.


Healthcare employers are obligated to provide a safe working environment free from recognised hazards, and failure to effectively abate the risk of violence can result in losses including fines, claims, litigation, and reputational damage.


However, employers' prevention efforts may be stymied by failure of victims to report violent incidents, because m any h ealthcare workers consider violence "part of the job."


Violent events can and do happen, and being unprepared is unacceptable. Although it is difficult to completely eliminate violence in healthcare settings, and although there is no "one-size-fits-all" approach for prevention, there are many ways to reduce the potential for violent occurrences and to minimise the impact if violence does occur. Risk managers committed to decreasing risk of violence in their organisations will need to convene stakeholders from various disciplines and collaborate to implement strategies, individualised according to identified risks, across the organisation.

The issue in focus


When violence erupts in a healthcare facility, the consequences are many and unpredictable, potentially including injury or death of building occupants, property damage, lawsuits, and diminished patient, staff, and community trust.


The risk of workplace violence looms in healthcare facilities—where a stressful work environment can quickly become volatile, visitors may be highly emotional, and drugs or expensive equipment may become targets of robbery. In addition, home care employees may walk alone into homes where patients or their family members keep weapons or drugs or may visit homes in areas with high crime rates, increasing the risk of encountering violence while on the job.


The National Institute for Occupational Safety and Health defines workplace violence as "violent acts, including physical assaults and threats of assault, directed toward personnel at work or on duty." Many other sources include verbal aggression (e.g. threats, verbal abuse, hostility, harassment) in the definition of workplace violence. Not only can verbal aggression cause significant psychological trauma and stress, it can also escalate to physical violence.




The Occupational Safety and Health Administration (OSHA ) reports that in each year from 2011 to 2013, U.S. healthcare workers suffered 15,000 to 20,000 serious workplace-violence-related injuries; serious injuries are those that require time away from work for treatment and recovery.


Violence is significantly more common in healthcare than in other industries, such that violence-related injuries to healthcare workers account for almost as many similar injuries sustained by workers in all other industries combined. In 2013, healthcare and social assistance workers experienced 7.8 cases of serious workplace violence injuries per 10,000 fulltime equivalents (FTE s), while other large sectors such as construction, manufacturing, and retail all had fewer than two cases per 10,000 FTE s.


Additionally, in 2016, the U.S. Government Accountability Office (GAO ) published an analysis of three federal datasets revealing that in 2013 healthcare workers at inpatient facilities such as hospitals experienced injuries from workplace violence that required time off at a rate that was five times that of overall private-sector workers.


According to OSHA, individuals other than patients, including visitors and coworkers, cause 20% of violent incidents in healthcare.


Organisational Perspective


Risk Factors


Healthcare workers face serious risks. The following risk factors for violence are inherent to the provision of healthcare:

  • Setting-specific vulnerabilities of acute care hospitals, emergency departments (EDs), community health clinics, drug treatment clinics, long-term care facilities, and private homes
  • Isolated work conducted alone or in small groups, in remote areas, or in areas with high crime rates
  • Late night or early morning work hours
  • The "economic realities of healthcare," such as reduction in staff, increased productivity pressure, patients and visitors who are experiencing difficult personal or financial circumstances
  • Exchange of money with the public
  • Transport and delivery of passengers, goods, or services.


High-Risk Areas


Certain clinical areas are particularly vulnerable to violence perpetrated by a family member or visitor.


Emergency Department (ED): Several factors predispose the ED to violence. As the main route of public access into the facility, EDs are often understaffed and overcrowded. The American College of Emergency Physicians cites the following factors that increase the risk of violence in EDs:

  • Presence of gangs
  • Long wait times for care, sometimes in undesirable environments
  • Influence of drugs and alcohol
  • Private citizens arming themselves
  • Presence of individuals requiring "medical clearance" after an arrest by law enforcement
  • Presence of individuals requiring psychiatric support in absence of sufficient dedicated mental health facilities


In one survey, more than 75% of emergency physicians reported experiencing at least one incident of workplace violence per year. Nearly as many emergency nurses reported verbal or physical assault by patients or visitors.


In a study of ED resident physicians published in 2016, in addition to reporting varying levels of violence perpetrated by patients, subjects reported experiencing the following types and rates of violence perpetrated by visitors:

  • Verbal harassment: 86.6%
  • Sexual harassment: 21.8%
  • Physical violence: 11.8%

Perhaps not surprisingly, nearly a quarter of the residents surveyed reported feeling safe at work "occasionally," "seldom," or "never."


Women's healthcare


Women's healthcare, including labour and delivery and the maternal-child health unit is a high-risk environment owing to the emotionally charged issues surrounding pregnancy and childbirth.


Intensive care unit (ICU)


Because the ICU cares for the most seriously ill patients, visitors to this area may be extremely distraught, stressed, and demanding of staff attention, which may—or may appear to be—in short supply. This combination can lead to verbal aggression toward staff and can escalate into physical assault, especially if staff are not properly trained in responding to distraught visitors.


Neonatal or paediatric ICU


Concerned parents may become violent while waiting to talk to a physician, while waiting for test results, or after finding out that their child has a serious disease. Divorced or estranged parents may come into conflict over their child's care in nurseries or on paediatric floors. Custody disputes may spill over into the hospital.


Parking lots and other exterior areas


Several factors can contribute to a parking area becoming the scene of violence. Parking areas may be dark, may offer many hiding places, and may be deserted at certain hours.


Home care


Home care workers, who often must enter patients' homes alone, are particularly vulnerable to violence. Home care workers may be exposed to unsafe conditions and have reported feeling threatened when they know that loaded weapons are present in a patient's home, or that drive-by shootings or gang violence have occurred in the neighbourhood.


Rats, other vermin, or hostile animals may be present, or housing may be in a deteriorated condition, or other situations may exist that suggest the potential for physical violence, verbal abuse, or sexual harassment by patients, family members, or visitors.


Action Recommendations

  • Develop and enforce comprehensive policies and procedures against workplace violence
  • Evaluate objective measures of violence to identify risks and risk levels
  • Train staff to recognise the warning signs of violent behaviour and respond proactively
  • Establish a comprehensive workplace violence prevention programme
  • Encourage all employees and other staff to report incidents of violence or any perceived threats of violence
  • Ensure appropriate follow-up to violent events, including communication, post-incident support, and investigation
  • Ensure that the violence prevention programme addresses the possibility of gun violence, including active shooters

ECRI Institute


ECRI Institute, a nonprofit organisation, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 45 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. ECRI ’s focus is medical device technology, healthcare risk and quality management, and health technology assessment. It provides information services and technical assistance to more than 5,000 hospitals, healthcare organisations, ministries of health, government and planning agencies, voluntary sector organisations and accrediting agencies worldwide. Its databases (over 30), publications, information services and technical assistance services set the standard for the healthcare community. More than 5,000 healthcare organisations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, healthcare processes, devices, procedures and drug technology. ECRI Institute is one of only a handful of organisations designated as both a Collaborating Centre of the World Health Organization and an evidence- based practice centre by the US Agency for healthcare research and quality in Europe. For more information, visit For access to the full Violence in Healthcare Facilities Report, go to: components/HRC/Pages/SafSec3.aspx

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