By Gary Evans, Medical Writer

A young woman in a traditional hijab head cover recently entered a Michigan hospital ED and walked up to the triage desk. Within seconds, she was attacked from behind by another patient, a man apparently enraged by her religious garb. She has fully recovered, but is suing the hospital for failing to protect her from assault.1

With reports of violence increasingly common, The Joint Commission (TJC) has issued a Sentinel Event Alert2 emphasizing that accreditation standards require measures to protect healthcare workers and patients.

“Workplace violence is a serious and prominent safety issue in healthcare,” Katie Bronk, TJC corporate communications, tells Hospital Employee Health. “We encourage our accredited organizations to use this alert to help their healthcare workers recognize violence from patients and visitors, become prepared to handle it, and more effectively address the aftermath.”

TJC has several accreditation standards that can apply to workplace violence prevention. These include Leadership and Rights and Responsibilities of the Individual, which require a “framework for safety and security of all persons in the organization,” the alert states.2 Other applicable standards include Provision of Care, Treatment, and Services, which address patient assessment and interventions. “Environment of Care standards address the physical environment and practices that enhance safety,” TJC notes. “Emergency Management standards address planning for more extreme risks of workplace violence, such as active shooters, community unrest, and terrorist attack.”

The goal is to work with healthcare facilities on workplace violence to address improvements in procedures and practices as guided by the accreditation standards, Bronk says.

“Should our Office of Quality and Patient Safety receive a report related to workplace violence, it will assess the concern as it relates to safety and quality to evaluate whether or not the report describes unsafe conditions or incidents,” she says. “Based on an analysis of the risk of harm in the report, an onsite survey or other action may be taken. Ultimately, if our surveyors identify an issue, the organization must address it or its accreditation status may be affected.”

The alert complements TJC’s web-based Workplace Violence Prevention Resources portal, which was launched several years ago to raise awareness of workplace violence. (The portal can be found at: The Occupational Safety and Health Administration (OSHA) was working on a violence prevention standard to protect healthcare workers, but that effort is in limbo in the current political climate.

The Joint Commission alert should spur action by healthcare facilities, some of which have too long taken the position that some level of violence comes with the chaotic territory of healthcare delivery.

“The Joint Commission is the biggest accrediting body for hospitals, so I think this will put some pressure on them,” says Patricia A. Lenaghan, RN, MSN, NE-BC, FAAN, senior healthcare clinical and operations analyst at Leo A. Daly in Omaha, NE. A former ED manager, Lenaghan is now with the Leo A. Daly architectural firm that designs violence prevention into new construction and renovations in healthcare. (See related story in this issue.)

The Joint Commission alert emphasizes the importance of creating “simple, trusted, and secure” reporting systems for incidents of violence and threats.

“Hospitals don’t necessarily track these events,” Lenaghan says. “Anytime you track something, it gets a lot more attention. You should not treat violence as part of normal operations or people get numb. Whether it is a verbal assault or physical, those should be tracked and reviewed by the quality team and hospital security. The Joint Commission can make that happen.”

Although shootings in healthcare are certainly occurring, the more common manifestation of violence in hospitals are assaults not involving a firearm, and verbal abuse. Recognizing verbal assault as a form of workplace violence that should not be overlooked, TJC cites the “broken window” theory that acceptance of insults eventually leads to injuries.

Approximately 11,000 healthcare workers are victims of assaults annually, and more than 50% of ED nurses experience verbal or physical assault regularly.3 The corrosive effects of the threat of violence contribute to low worker morale and high job turnover, both of which contribute to staff burnout.

TJC’s Sentinel Event Alert calls for a comprehensive system analysis of events that lead to death, permanent harm, or severe temporary harm to patients and healthcare staff, including rape and assault.

“While the policy does not include other forms of violence, it is up to every organization to specifically define acceptable and unacceptable behavior and the severity of harm that will trigger an investigation,” the alert states. “Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats.”

Gathering Storm

Something close to the proverbial perfect storm seems to be taking shape: A healthcare system under pressure faces an opioid epidemic, which is exacerbated by breakdowns followed by the lack of mental health services in many communities.

“The most common characteristic exhibited by perpetrators of workplace violence is altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness,” TJC states. “Increasingly, hospitals are providing care for potentially violent individuals.”

This is particularly true in the ED, where on any given night patients may show up in the aftermath of domestic assault or gang activity, or under the influence of the powerful opioids that are offered on the streets.

“Any time you have a patient that’s under the influence of any kind of drug — alcohol, opioids, other narcotics — it creates an environment where people cannot control their behavior,” Lenaghan says. “There is also a lot of tension in the families because they have been dealing with these issues for quite some time and then they get a call, and they come to the ER. It creates a lot of anxiety.”

This volatile situation is ratcheted up further by the possible involvement of drug dealers or gang members, she adds. “It creates a lot of challenges for the staff,” she says.

The Sentinel Event Alert emphasizes that healthcare workers must be alert and ready to act when they encounter verbal or physical violence from patients or visitors who may be under stress or “who may be fragile, yet also volatile,” TJC states.

“You have to always remind yourself that you are there to take care of a very vulnerable patient,” Lenaghan says.

Healthcare organizations are encouraged to address this growing problem by looking beyond solutions that only increase security, TJC advises.

In that regard, reporting systems and prevention efforts are the responsibility of healthcare organization — not the victims of violence at the facility.

“It’s important for organizations to communicate a zero-tolerance attitude toward workplace violence and unnecessary risks,” says Cory Worden, MS, CSHM, CSP, CHSP, ARM, REM, CESCO, manager of system safety at Memorial Hermann Health System in Houston. “This drives the safety culture and helps to reverse the unfortunate perception of workplace violence in healthcare being ‘just part of the job’ or ‘the cost of doing business.’”

Other administrative or work practice solutions may include developing workplace violence response teams and policies, the alert recommends. Beyond that, train all staff — including security — in de-escalation, self-defense, and response to emergency codes.

“When threatening language and agitation are identified, initiate de-escalation techniques quickly,” TJC reports. “Regarding de-escalation and self-defense, experts suggest that hospitals prohibit firearms from campus, except for […] law enforcement officers. The Centers for Medicare & Medicaid Services does not permit the use of weapons by any hospital staff as a means of subduing a patient.”

Conduct practice drills that include response to a full spectrum of violent situations, which could range from a verbally abusive family member to an active shooter, TJC notes.

“These practice drills can be part of an ongoing safety program, as indicated in The Joint Commission Environment of Care (EC) standards,” the alert states. “However, a situation such as an active shooter requires more extensive coordination with community responders, and can be addressed in exercises as described in the Emergency Management (EM) standards.”

TJC recommends violence prevention efforts be periodically assessed for effectiveness, looking at the following areas:

• reported incidents and leadership’s responses to them;

• trends in incidents, injuries, and fatalities relative to baseline rates and measuring improvement;

• surveying workers to determine effectiveness of initiatives;

• tracking if recommendations were completed.

“By ‘tracing the cord back to the wall,’ we can determine what gaps exist in which workplace violence can develop,” Worden says. “If violence becomes imminent, employees will need to know defensive techniques to egress the area with minimal injury, if any. This requires specific training and conditioning to ensure these techniques are not only known, but ready for use in an escalating situation.”


1. Hicks, M. Suit: Woman attacked in Beaumont Dearborn ER. The Detroit News March 30, 2018. Available at:

2. The Joint Commission. Physical and verbal violence against health care workers. Sentinel Event Alert 59: April 16, 2018. Available at:

3. Thompson, P. Mitigating violence in the workplace. Hospitals in Pursuit Of Excellence Webinar, American Hospital Association and American Organization of Nurse Executives, 2015.