In recently issued guidelines on preventing violence, the Occupational Safety and Health Administration outlines key strategies to reduce hazards in high-risk health care environments.1 Violent events are not completely predicable, but OSHA identified risk factors in patients and institutional cultures that can set the stage for an incident.

“While no specific diagnosis or type of patient predicts future violence, epidemiological studies consistently demonstrate that inpatient and acute psychiatric services, geriatric long term settings, high volume urban emergency departments and residential and day social services present the highest risks,” OSHA reports. “Pain, devastating prognoses, unfamiliar surroundings, mind and mood altering medications and drugs, and disease progression can also cause agitation and violent behaviors.”

In addition, an individual hospital may have inherent risk factors for such incidents, including lack of facility policies and staff training for recognizing and managing escalating hostile behavior. According to OSHA, institutional risk factors include:

• Working when understaffed — especially during mealtimes and visiting hours

• High worker turnover

• Inadequate security and mental health personnel on site

• Long waits for patients or clients and overcrowded, uncomfortable waiting rooms

• Unrestricted movement of the public in clinics and hospitals

• The perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges

If an incident occurs, make every effort to get to the root causes, OSHA urges: “Don’t stop an investigation at ‘worker error’ or ‘unpredictable event.’ Ask ‘why’ the patient or client acted, ‘why’ the worker responded in a certain way, etc.”

Investigate “near misses,” as well, as these situations that could have escalated into violence may provide insights into prevention. “Near misses are caused by the same conditions that produce more serious outcomes, and signal that some hazards are not being adequately controlled, or that previously unidentified hazards exist,” OSHA states.

Overall, OSHA recommends five elements as the building blocks of a violence prevention program.

Management commitment and worker participation: This includes articulating a policy and goals, allocating adequate resources, and holding managers, supervisors and workers accountable. A “comprehensive program of medical and psychological counseling” should be available to workers who witness or experience violent events. Frontline workers should be involved in the development and implementation of violence prevention programs.

Worksite analysis and hazard identification: A team that includes senior management, supervisors and workers should identify existing and potential hazards. This includes a records review, employee surveys and workplace security analysis. The team would then identify control measures and appropriate training.

Hazard prevention and control: Employers should take appropriate steps to prevent or control the identified hazards and periodically evaluate the effectiveness. This includes physical changes, such as barriers, panic buttons and better lighting, and work practice changes, such as adjusting staffing levels, identifying patients with a history of violence, and other safety measures.

Safety and health training: All workers, including contractors and temporary employees, should receive training on the workplace violence prevention program at least annually. Those in high-risk settings should receive training as often as monthly or quarterly with a focus on specific hazards. “Every worker should understand the concept of ‘universal precautions for violence’— that is, that violence should be expected but can be avoided or mitigated through preparation,” OSHA says.

Recordkeeping and program evaluation: Employers should track the effectiveness of the prevention program by using OSHA logs, medical reports of worker injury, information on patients with a history of violence, security reports and other documents and records. Monitoring should include surveys of employees regarding hostile situations they encounter on the job. “Responsible parties (including managers, supervisors and employees) should reevaluate policies and procedures on a regular basis to identify deficiencies and take corrective action,” OSHA says.


  1. Occupational Health and Safety Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2015: