Quick Safety 5: Preventing violent and criminal events (Updated June 2021)

Update June 2021

Issue:

Anyone in a health care facility can become a victim of violence. During the 2010-2020 timeframe, The Joint Commission received 456 reports from its accredited organizations of violent and criminal events. Excluding the 39 reports of shootings reported in Quick Safety Issue 4, the remaining 417 reports in the Joint Commission’s Sentinel Event database include 249 reports of sexual assault including rape, 109 reports of physical assault resulting in injury, and 61 reports of homicide with 69 of those deaths from physical assault. Of the 417 reports:

• 261 were patient-on-patient violence (156 sexual assaults, 66 physical assaults, and 39 homicides).
• 85 were staff-on-patient violence, with the majority (74) being sexual assaults. 
• 38 were patient-on-staff violence (22 caused by beating, punching or kicking; 9 stabbings; and five sexual assaults).

More than half of the 456 reports were committed by and/or on behavioral health/psychiatric patients, or in a behavioral health setting. This data is consistent with literature reports of criminal events and violence in health care settings.

Of the homicides, the majority were caused by beating, punching or kicking (30), strangulation or asphyxiation (12), or stabbing (10). The majority of physical assaults involved beating, punching or kicking (80) or stabbing (17). Of the injuries sustained, the most common were head injury or head trauma, facial fractures, or eye injury or blindness.

Safety Actions to Consider:

While risk factors for violence vary depending on the facility and the patient population, the following general prevention strategies may be considered, especially if your organization’s patient population includes behavioral health or psychiatric patients.

Identify risks and plan to reduce those risks

• Form a multidisciplinary committee (such as the environment of care or safety committee) that includes direct-care staff and union representatives (if available) to identify risk factors in specific work scenarios and to develop risk reduction strategies.
• Conduct a -worksite analysis of the organization, including geographic location and service area, as violent offenders may travel to your site seeking services. 
• Conduct an assessment of risks associated with the patient population. Periodically reassess for those risks and any new risks.
• In non-acute care settings, determine admission and exclusionary criteria for patients who have a history of violence and who pose a risk to existing patients and staff.
• Survey employees to determine how safe they feel while working, and how prepared they are for handling violent situations.
• Maintain an ongoing dialogue with local law enforcement regarding risk factors in the community (for example, gangs), and the local crime rate. Although the facility may be located in a low crime area, patients and their families may be from other areas. Implement a comprehensive violence prevention program and periodically evaluate the program.
• Implement a plan to address identified risks and update the plan as new information is presented. For example:
• Hospitals may consider having the security lead on each shift meet with the charge nurse on each open unit to dialogue regarding emerging issues or may instruct EMTs to take rival gang victims to separate hospitals (if clinically appropriate).
• Behavioral health care programs may consider having a daily shift meeting to alert the team about risk factors related to newly admitted patients or new risk factors in the existing patient population.
• Community and home-based programs may consider changing the locations for providing service when there are risks present in the area in which a patient’s home is located.

Environmental design

• Develop emergency signaling, alarms, and monitoring systems.
• Install security cameras and panic buttons.
• Improve lighting in hallways, rooms, clinical offices and parking areas.
• Provide security escorts to the parking lots at night.
• Design the triage area and other public areas to minimize the risk of assault. Some strategies may include:
• Provide staff restrooms and emergency exits.
• Install enclosed nurses' stations.
• Install deep service counters in, or enclose, reception areas.
• Arrange furniture so that staff can easily access the closest exit.
• Minimize the presence of objects that could be used as weapons.
• Make waiting areas comfortable and accommodating.
• Restrict the movement of the public by using card-controlled access.

Administrative controls

• Design staffing patterns to prevent personnel from working alone and to minimize patient waiting time.
• Develop a system for alerting security personnel and other staff when violence is threatened.
• Flag charts of patients who have exhibited prior violent behavior. Establish a clear expectation that threatening and violent behavior will not be tolerated, and communicate how this behavior will be addressed up, to and including discharge or transfer from care.
• Consider establishing a police check-in station or substation.

Training

• Work with local law enforcement to provide employees with crime prevention training. 
• Train staff to recognize and manage assaults, resolve conflicts, and maintain hazard awareness. Training should address how to manage crises with potentially volatile patients and visitors, especially those under the influence of drugs or alcohol, or those who have a history of violence or certain psychotic diagnoses.
• Provide staff with tips on how to be alert and cautious when interacting with patients and visitors. 
• Familiarize staff with policies, procedures and materials on violence prevention.

Safety culture

• Foster a safety culture where employees are comfortable reporting events to management, security and law enforcement. Make the reporting system easy and accessible for staff.

Plan for post-event activities

• Foster a safety culture that promotes open communication.
• Develop written procedures for reporting and responding to violence.
• Offer and encourage counseling whenever a worker is threatened or assaulted.

Resources:

• Centers for Disease Control and Prevention (CDC), The National Institute for Occupational Safety and Health (NIOSH): 
  •  About Workplace Violence
  • Online Workplace Violence Prevention Course for Nurses
  • Violence Occupational Hazards in Hospitals (includes prevention strategies)
• International Association for Healthcare Security and Safety (IAHSS): Security Design Guidelines for Healthcare Facilities, 3rd Edition, 2020
• National Association of Psychiatric Health Systems: Design Guide for the Built Environment of Behavioral Health Facilities, Edition 6.2, March 25, 2014
• National Research and Training Center (NRTC): Crisis De-Escalation Training for Staff and Consumers in Inpatient and Other Service Delivery Settings
• The Joint Commission: Sentinel Event Alert Issue 45: Preventing violence in the health care setting, June 3, 2010
• The Joint Commission: “Security safety: Employee training lowers violence risks at hospitals.” Environment of Care News, Volume 15, Issue 3, March 2012
• The Joint Commission: “Violence code reload: Ft. Lauderdale hospital launches successful new violence prevention program.” Environment of Care News, Volume 16, Issue 11, November 2013
• Joint Commission: “Engineering solutions to workplace violence: Prevent workplace violence via safety-enhancing design and equipment.” Environment of Care News, Volume 17, Issue 3, March 2014
• The Joint Commission: Quick Safety Issue Four: Preparing for active shooter situations, Updated June 2021
• The Joint Commission’s Workplace Violence Prevention Resources Portal 

Note: This is not an all-inclusive list. 

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert. The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations. The information in this publication is derived from actual events that occur in health care.

©The Joint Commission, Division of Health Care Improvement