The Occupational Safety and Health Administration (OSHA) recently unveiled a new webpage ( with tools and real-world examples to prevent and defuse violent incidents in the healthcare workplace. The website was launched Dec. 1 as this issue was going to press, but look for more news and analysis on OSHA’s increasing emphasis on violence prevention and any implications for compliance in the next issue of Hospital Employee Health.

It appears there are no specific new regulatory requirements in this latest emphasis on violence prevention, but OSHA inspectors have some leeway under their General Duty clause requirement that employers provide a workplace that is “free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

In any case, it looks like OSHA is more interested in integrating violence prevention into existing patient and worker safety efforts rather than breaking it out as a separate regulatory area.

“Doing so makes sense, because many of the risk factors that affect patient safety also affect workers,” OSHA says on the website. “For instance, a violent confrontation or intervention can result in injuries to both workers and patients, and caregiver fatigue, injury, and stress are tied to a higher risk of medication errors and patient infections.”

A dangerous job

The scale of the problem is striking. Registered nurses have more than a threefold higher risk of violent injury resulting in days lost (14 per 10,000 nurses) than U.S. private industry as a whole, which suffers 4.2 lost-day violent injuries per 10k full-time employees, OSHA reports. That’s a terrible toll on a force on a highly trained professionals, but consider this: Workers classified as “nursing assistants” have injury levels off the charts, more than tripling the rate in RNs with 55 injuries per 10k full-time employees.

The most common causes of violent injuries resulting in days away from work across several healthcare occupations were hitting, kicking, beating, and/or shoving. As expected, patients are the cause of most violent injuries (80%), with 3% caused by co-workers and the rest committed by unnamed “others” that include visitors. The numbers are underestimates in any case, as OSHA cites a Minnesota survey of 4,738 Minnesota nurses found that only 69% of physical assaults were reported. Employee health professionals should look at their programs in terms of these common reasons given by nurses who did not report an act of violence: lack of a reporting policy, little faith in the reporting system, and fear of retaliation.1

The new OSHA strategies and tools focus on workplace violence prevention programs that include elements such as management commitment and worker participation, worksite analysis and hazard identification, safety and health training, record-keeping and ongoing program evaluation.

In an example cited by OSHA, St. Vincent’s Medical Center in Bridgeport, CT, begins every day with a “safety huddle” led by a senior executive. Representatives from all departments, including both clinical and non-clinical services, are required to attend. Together, they review any patient or associate safety events or concerns, recognize “good catches” (aka “near-misses”), and share updates on the status of safety-related projects or initiatives.

“These daily exchanges, fostered in an open, no-blame environment, help create an atmosphere of trust and cooperation,” OSHA reports.

There are OSHA recommended strategies for specific patient encounters as well, such as “tapping out” when a patient is becoming increasingly irritated with a healthcare worker trying to provide care. At Providence Behavioral Health Hospital in Holyoke, MA, co-workers are encouraged to recognize this type of situation and “tap in” by telling the first worker something like, “You have a phone call — and it’s your supervisor.” Sometimes all it takes is a new face to get a patient to calm down, and an emphasis on “caring language” allows the first worker to exit the situation gracefully, OSHA notes.

“This type of focus on collaboration and respectful language is a hallmark of a “culture of safety,” the agency says.

In addition, the tools used to monitor, manage, and improve patient safety have proven equally effective when applied to worker safety.

“For example, if your facility is Joint Commission accredited, you may be able to adapt existing compliance monitoring tools and infrastructure to address occupational safety,” OSHA explains. “Several hospitals use their ‘environment of care’ rounds to monitor for conditions that could affect either patient or worker safety.”

Strategies to improve patient safety and worker safety can go hand-in-hand — particularly those that involve nonviolent de-escalation and alternatives such as sensory therapy. The nationwide movement toward reducing the use of restraints (physical and medication) and seclusion in behavioral health — which is mandated in some states — along with the movement toward “trauma-informed care,” means that workers are relying more on approaches that result in less physical contact with patients, intervening with de-escalation strategies before an incident turns into a physical assault, preventing self-harm by patients, and ultimately equipping patients with coping strategies that can help them for life.

Employee health professionals should look at their work culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior. All of these determine the organization’s commitment to objectives such as quality and safety. Many leading healthcare organizations are reducing injuries to both patients and workers by fostering a “culture of safety” characterized by an atmosphere of mutual trust, shared perceptions of the importance of safety, confidence in the efficacy of preventive measures, and a no-blame environment. According to OSHA, typical attributes of a culture of safety include the following:

  • staff and leaders who value transparency, accountability, and mutual respect,
  • safety as everyone’s first priority,
  • not accepting behaviors that undermine the culture of safety,
  • a focus on finding hazardous conditions or “close calls” before injuries occur,
  • an emphasis on reporting errors and learning from mistakes, and
  • careful language to facilitate conversation and communicate concerns.


  1. Gerberich, SG, Church, TR, McGovern, PM, et al. An epidemiological study of the magnitude and consequence of work related violence: The Minnesota Nurses’ Study. Occup Environ Med 2004;61:495–503.