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Joint Commission Alert:
Violence is rising
A new Joint Commission Sentinel Event Alert warns that health care providers today are being confronted with steadily increasing rates of crime, including assault, rape, and murder.
The Sentinel Event Alert urges greater attention to the issue of violence and to controlling access to facilities to protect patients, staff, and visitors, noting that assault, rape, and homicide are consistently in the top 10 types of serious events reported to The Joint Commission. The Alert cautions that the actual number of violent incidents is significantly under-reported and advises organizations to mandate the reporting of all real or perceived threats.
The Alert points out that administrators must be alert to the potential for violence to patients by health care staff members. "The stressful environment together with failure to recognize and respond to warning signs such as behavioral changes, mental health issues, personal crises, drug or alcohol use, and disciplinary action or termination, can elevate the risk of a staff member becoming violent towards a patient," it says. "Though it is a less common scenario, health care workers who deliberately harm patients by either assaulting them or administering unprescribed medications or treatments, present a considerable threat to institutions, even when the patient is unable to identify the responsible person."
Human resources staff members play a critical role in developing and following through on hiring, firing, and disciplinary practices, which should be supported by management, and in performing thorough criminal background checks on all new hires, the Alert says. Because criminal background checks are costly, at a minimum, organizations may want to conduct criminal background checks on job candidates who are to be placed in high risk areas, such as home care, it says.
Joint Commission suggested actions
The following are suggested actions that health care organizations can take to prevent assault, rape and homicide in the health care setting. Some of these recommendations are detailed in the September 2005 issue of Healthcare Risk Control (HRC) available online at www.ecri.org/Forms/Pages/Violence_in_Healthcare_Facilities.aspx.
Work with the security department to audit your facility's risk of violence. Evaluate environmental and administrative controls throughout the campus, review records and statistics of crime rates in the area surrounding the facility, and survey employees on their perceptions of risk.
Identify strengths and weaknesses and make improvements to the facility's violence-prevention program. (The HRC issue includes a self-assessment questionnaire that can help with this.)
Work with the human resources (HR) staff members to make sure they thoroughly prescreen job applicants, and establish and follow procedures for conducting background checks of prospective employees and staff. For clinical staff, the HR staff also verifies the clinician's record with appropriate boards of registration. If an organization has access to the National Practitioner Data Bank or the Healthcare Integrity and Protection Data Bank (www.npdb-hipdb.hrsa.gov/index.html), check the clinician's information, which includes professional competence and conduct.
Confirm that the HR staff members ensure that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction.
Require appropriate staff members to undergo training in responding to patients' family members who are agitated and potentially violent. Include education on procedures for notifying supervisors and security staff. (Editor's note: The Joint Commission credits the American Society of Health-System Pharmacists: Policy Position on Education, Prevention, and Enforcement Concerning Workplace Violence with this tip. That policy position is available online at www.ashp.org/DocLibrary/BestPractices/HRPositions09.aspx.)
Ensure that procedures for responding to incidents of workplace violence (e.g., notifying department managers or security, activating codes) are in place and that employees receive instruction on these procedures.
Encourage employees and other staff to report incidents of violent activity and any perceived threats of violence.
Educate supervisors that all reports of suspicious behavior or threats by another employee must be treated seriously and thoroughly investigated. Train supervisors to recognize when an employee or patient may be experiencing behaviors related to domestic violence issues.
Ensure that counseling programs for employees who become victims of workplace crime or violence are in place.
Should an act of violence occur at your facility whether assault, rape, homicide or a lesser offense follow-up with appropriate response that includes:
reporting the crime to appropriate law enforcement officers;
recommending counseling and other support to patients and visitors to your facility who were affected by the violent act;
reviewing the event and making changes to prevent future occurrences.
"Health care facilities should be places of healing, not harm. But, unfortunately, health care settings are not immune from the types of violence that are found in the other areas of our lives," says Mark R. Chassin, MD, MPP, MPH, president, The Joint Commission. "The recommendations in this Alert give health care institutions and caregivers specific strategies to take action that will keep everyone safer."
Causes of health care violence
Of the information in the Sentinel Event Database regarding criminal events, the following contributing causal factors were identified most frequently over the last five years:
leadership, noted in 62% of the events, most notably problems in the areas of policy and procedure development and implementation;
human resources-related factors, noted in 60% of the events, such as the increased need for staff education and competency assessment processes;
assessment, noted in 58% of the events, particularly in the areas of flawed patient observation protocols, inadequate assessment tools, and lack of psychiatric assessment;
communication failures, noted in 53% of the events, both among staff and with patients and family;
physical environment, noted in 36% of the events, in terms of deficiencies in general safety of the environment and security procedures and practices.
Problems in care planning, information management and patient education were other causal factors identified less frequently.
The publication also outlines:
techniques for identifying potentially violent individuals;
violence de-escalation tools that health care workers can employ;
violence management training;
conducting a violence audit;
conducting a violence assessment walk-through;
responding in the wake of a violent event.
In addition to the specific recommendations contained in the Alert, The Joint Commission urges facilities to comply with the requirements described in its accreditation standards to prevent violence. The standards require accredited health care facilities to have a security plan as well as conduct violence risk assessments, develop strategies to prevent violence and have a response plan when a violent episode occurs. The Joint Commission's standards also are clear that patients have a right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
The warning about violence in health care facilities is part of a series of Alerts issued by The Joint Commission. Much of the information and guidance provided in these Alerts is drawn from The Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed health care technology, anticoagulants, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of the Sentinel Event Alert can be found on The Joint Commission Web site at www.jointcommission.org. Under "Sentinel Event," select "Sentinel Event Alert."