When a surgeon was shot and killed by a patient at a nearby hospital in 2015, clinicians at the University of Massachusetts Memorial Health Care in Worcester overhauled its comprehensive violence prevention program.

The incident that shook the Boston area medical community was the murder of a popular and highly skilled surgeon at Brigham and Women’s Hospital by a relative of a deceased patient. (For more information, see the January 2017 issue of Hospital Employee Health.)

“When that happened, it really caused a lot of concern because it was just down the street from us. A violence prevention task force was created,” said Maria Michas, MD, MPH, FACOEM, medical director of employee health at UMass. Michas chairs the task force, and updated the program recently in Anaheim, CA, at the annual meeting of the American College of Occupational and Environmental Medicine (ACOEM).

“There was a lot of work being done in silos, but this was an effort to really bring together the key stakeholders who had a direct interest or were already working on projects in violence prevention,” she said.

In addition to reviewing and updating policies and procedures on workplace violence, UMass created an interdisciplinary rapid response team.

“If a situation is escalating, we can quickly call in this team to help with violent patients in the emergency department or on the [hospital] floors,” she said.

It is no easy task to ensure rapid response to all units and shifts 24/7, she notes. The many challenges of violence prevention are reflected in the size of the task force, which includes representatives from numerous departments and several subgroups.

For example, a policy subgroup reviews and updates plans in such areas as patient visitation, restraint, searches of visitors and patients, and domestic violence leave of absence for employees. A subcommittee on procedures routinely monitors security measures; for example, assessing the metal detectors, which were added to the ED in 2017.

“We have close contact with the police if a handgun, drugs, or things like that are found,” Michas said. “We also have panic buttons, and there is a procedure for asking for one in your department if you need another one.”

The task force also is evaluating wearable devices that can be used to sound an alarm and send a GPS location signal. “We are looking at other technology,” she said. “If a patient is standing between you and the panic button, it is not going to do you any good.”

Security staff conduct routine walkthroughs every shift, responding to loitering and suspicious behavior or situations. “They are looking for things like secured doors, any suspicious packages, or people in the areas,” Michas said. “The managers of the units are really tasked with making sure all of the security equipment is working in their areas; making sure their card readers, cameras, and alarms are working.”

In addition to training staff in recognizing and responding to violent threats, the task force created work-culture Standards of Respect with the input of employees.

“This came about because our caregivers and employees’ recognition that a more respectful culture was needed based on incidents of disrespect they were experiencing or witnessing,” she said. “If people are feeling disrespected, they are more likely to leave your organization. Increased stress could also lead to absenteeism and decreased productivity.”

In a 2016 survey, employees identified behaviors that help them, patients, and families feel respected and supported, she said. The resulting standards have become an organizational priority, with required employee participation in a series of workshops. About half of the hospital employees have received the training. As described by Michas, the standards of respect adopted at UMass are summarized as follows.

• Acknowledge: Notice others and recognize their concerns;

• Listen: Give full attention;

• Communicate: Share appropriate information with those who need it;

• Respond: Respond in the expected time frame;

• Team player: Work in a way that helps colleagues;

• Kindness: Be kind, friendly, and patient — even when it is not easy.

“Unfortunately, people don’t always behave this way,” she said. “There is a lot of roleplaying in the classes so that you can learn and practice these behaviors. It is a little too early to tell if this is making a difference in our facility, but it is leading to more reports of bullying and other incidents. It is going to be interesting down the road when the entire organization gets trained.”

The violence prevention program at UMass encourages reporting of “near misses,” Michas added. “If you see something, say something,” she said. “Don’t wait until there is an actual assault. If you see aggressive behavior going on with a patient or co-worker, you need to report it.”

Incidents are tracked and updated at a daily safety briefing.

“That is not just the employee health service on these calls, but it is across the institution,” she said.

Security Staff Injuries

Another study presented at the ACOEM meeting revealed a high rate of injuries in security personnel responding to violent incidents in the ED, reported Khaula Khatlani, MBBS, MSc, a resident in the Yale School of Medicine.

National hospital workplace violence reports are approximately six incidents per 1,000 employees annually, she tells Hospital Employee Health. “That rate was for the overall hospitals,” Khatlani says. “As we looked at only the emergency department setting, we are expecting a higher rate. It turned out to be way higher. We were interested in looking at different job categories to see if the injury rates differed.”

Researchers reviewed 107 workplace violence injuries reported in the ED between Oct. 1, 2015, and May 18, 2017. They found a rate of 31 per 1,000 ED employees, she says, noting that studies of workplace violence traditionally do not include security personnel.

“Security personnel had a much higher rate,” Khatlani says. “They actually [comprise] only 6% of the total work force in the emergency department. However, 20% of them reported workplace violence injuries.”

That compares to 6% of the nurses and ED techs reporting workplace violence injuries for the period. A longitudinal follow-up study over a longer period is underway to assess injuries in the ED and the reporting of job categories.

“We looked at all the injuries that were being reported in an association with aggression,” she says. “These data are based on physical violence that resulted in injuries. The other aspect is verbal abuse, which was not captured in this database because that is not being actively reported.”

Injuries included in the report resulted from slaps, kicks, punches, spitting, and biting. “There was one injury where the employee had a fractured nose because he was hit in the face by a patient who was about 10 years old,” she says.

The inclusion of security personnel in violent injury data may make Yale a comparative outlier to studies of clinicians only, but it highlights an important area of occupational risk. “If we excluded them, we would expect the overall injury rate to go down,” Khatlani says. “However, we feel that the ED is a setting where people are frequently combative and aggressive. They are coming in with substance abuse disorders and somebody needs to calm them down. Usually, it is the security personnel — the [healthcare workers] taking care of an aggressive patient call them for help.”

To recognize and defuse potentially violent patients, Yale is using the Brøset Violence Checklist developed by researchers in Norway.1 The tool is used in patient observation, noting patient signs and symptoms that include confused, irritable, verbal, and physical threats, and attacking objects. The more symptoms the patient manifests, the greater the likelihood of violence. Similarly, as they are reduced or not expressed, the patient is considered less potentially violent.


  1. Woods P, Almvik R. The Brøset violence checklist (BVC). Acta psychiatrica Scandinavica 2002;106:103-105.