The Occupational Safety and Health Administration (OSHA) has ineffective enforcement programs for issuing citations and following up warnings for workplace violence in healthcare, the U.S. General Accountability Office (GAO) reports.1

While the number of inspections involving workplace violence in healthcare facilities has increased, a relatively small percentage of these inspections resulted in general duty clause citations related to workplace violence, the government watchdog group found. From 1991 through October 2014, OSHA issued 18 general duty clause citations to healthcare employers for failing to address workplace violence. Seventeen of these citations were issued from 2010 through 2014. These citations were issued in about 5% of the 344 workplace violence inspections of healthcare employers that were conducted from 1991 to April 2015, the GAO reported.

The GAO recommended that OSHA provide additional information to assist inspectors in developing citations, develop a policy for following up on hazard alert letters concerning workplace violence hazards in health care facilities, and assess its current efforts. OSHA agreed with GAO’s recommendations and stated that it would take action to address them, including considering whether a separate standard is needed on workplace violence in healthcare.

As has been previously reported, healthcare workers suffer much higher rates of violent injuries than the overall work sector. According to the GAO, in 2011 nonfatal workplace violence injuries in healthcare were an estimated 40,000 incidents.

“The full extent of the problem and associated costs is unknown,” the GAO noted in the report.

That’s due in part to the fact that such injuries are not always reported by healthcare workers. OSHA has increased its education and enforcement efforts to help employers address workplace violence in healthcare facilities, but GAO identified the several areas for improvement.

While OSHA does not have a standard on preventing workplace violence, the agency can use its general duty clause to protect workers from violence. The GAO reported, however, that OSHA regional offices lack specific criteria to enforce violence prevention under the general duty clause. Specific examples of issues that have been or could be cited are needed, the GAO recommended.

OSHA inspectors can also issue warnings about violence prevention, but employers can essentially ignore these “hazard alert letters,” and OSHA does not follow up to see if corrective actions were taken. As a result, identified hazards may persist, the GAO found.

“OSHA has not fully assessed the results of its efforts to address workplace violence in healthcare facilities,” the GAO concluded. “Without assessing these results, OSHA will not be in a position to know whether its efforts are effective or if additional action may be needed to address this hazard.”

In response to the report, OSHA said it agreed with GAO recommendations and is taking action. The agency is in the process of revising its enforcement directive and developing a training course to further assist inspectors, OSHA stated in letter that is included in the GAO report. OSHA also plans to include standardized procedures for following up on hazard alert letters in the revised enforcement directive. OSHA stated that it intends to find a cost-effective way to gauge its enforcement efforts to determine whether additional measures, such as developing a workplace violence prevention standard for healthcare workers, are necessary. In addition, OSHA stated that the agency is reviewing past inspections that resulted in citations or hazard alert letters to determine what measures may improve the process, the GAO reported.


  1. GAO: Workplace Safety and Health: Additional Efforts Needed to Help Protect Health Care. April 14, 2016: