2 incidents raise concerns: How do you protect staff and patients from violence?
By Joy Daughtery Dickinson, Executive Editor
In November, a patient's son ran through Good Shepherd Ambulatory Surgical Center in Longview, TX, with a hunting knife and screamed, "You're not going to kill my mother." He stabbed and killed a nurse and a patient's father and injured three others. The 22-year-old attacker ran from the scene but soon was caught and arrested.
In December, a former patient who claimed to have had a botched vasectomy three years ago opened fire at Urology Nevada in Reno. He fatally shot the urologist and injured two others before fatally shooting himself. He had posted Yahoo messages for years saying his doctors were responsible for his declining health. In his postings, he said he had learned that immune reactions, nerve damage, and back pressure issues could result from vasectomy, but he claimed not to have been informed of these potential side effects.
Incidents of violence are not uncommon, particularly in healthcare. Since 2000, an average of 552 work-related homicides occurred annually in the United States.1 A 2012 report said 27% of businesses had experienced an incident of workplace violence within the last five years.2 Sixty-one percent of workplace assaults are by healthcare patients or residents of a healthcare facility.3
Employers are obligated, under the Occupational Safety and Health Administration (OSHA) General Duty Clause, to provide a workplace "free from recognized hazards that are causing or likely to cause death or serious physical harm." In some cases, workplace violence prevention has been accepted as falling under the General Duty Clause, according to the National Institute for Prevention of Workplace Violence in Lake Forest, CA. "Additionally, any incident will likely trigger an OSHA investigation, which could result in a fine," the institute says.1
If you don't have security, what do you do?
The recent incidents of violence raise concerns among outpatient surgery managers, particularly those who work in offices or facilities where there is no security staff.
"While it is certainly not possible to prevent all incidents of workplace violence because they depend on the quirks and variability of human behavior, the vast majority of incidents are preventable if organizations take the potential threat of workplace violence as a serious one and invest in the necessary level of pre-planning and preparation," says Barry Nixon, SPHR, executive director of the National Institute for Prevention of Workplace Violence and publisher of The Workplace Violence Prevention eReport. "High levels of planning, preparing, and focus on prevention will reduce the need for reaction and response," Nixon says. Workplace violence experts suggest these steps:
. Establish policies and procedures.
"Policies and procedures can be put in place so that employees know what is expected of them to identify and address potentially violent situations," says Corinne Peek-Asa, PhD, director of the Injury Prevention Research Center at the University of Iowa in Iowa City.
Establish a multidisciplinary team to develop and implement procedures for reporting and communicating about events, she says. "This can be in the form of a safety committee or a threat management team," Peek-Asa says.
. Educate your staff.
Train all employees on policies and procedures, as well as offering general training on patterns of, signs of, and response to potentially violent situations, Peek-Asa says. (See "The Unlucky 13: Early Warning Signs of Potential Violence at Work," p. 39.)
"While the tendency of healthcare is to focus on patient violence, it is also important to include worker-on-worker violence, intimate partner violence, and the potential for robbery," she says.
Don't stop with staff, Nixon says. "Supervisors should be educated about the firm's workplace violence prevention policy and program which defines their responsibilities including legal requirements, how to handle information reported to them or that they observe, identification of early warning signs, and how to intervene and what to do if an incident occurs," he says.
James Bray, police area representative of the Longview Police Department, teaches a two-hour class on how to respond to violence, but for those with time limitations, Bray and others point to a 6-minute YouTube video titled "Run! Hide! Fight!" developed by the City of Houston. Access it at http://binged.it/1e1nsQV.
Bray was told that employees responded well to the stabbing at the Longview center. Visitors who couldn't get out of the building were locked in exam rooms and offices. Ensure that your patient rooms can be locked from the inside, Bray says. Another option is to put furniture in front of a door. If it's necessary to fight, "have the mindset that I'm going to fight with everything I have, and I'm going to be the one who walks away from the incident," Bray says.
If you use packaged educational programs, augment them with information specific to your worksite, Peek-Asa advises.
. Train employees and hold drills.
In terms of violence prevention, "everyone has hurricane drills, tornado drills, but no one ever has that type of drill," Bray says.
He suggests that you ask employees to sit or stand at their normal workstations and answer these questions: Where is the closest exit? Where will I hide if I need to hide? What do I have available to use as a weapon if I need it? Also consider how you can help protect patients during the threat.
Conduct scenario exercises as a tabletop exercise or a simulated scenario, Peek-Asa suggests. "Scenarios focused on upstream identification [of potentially violent situations] and response are most helpful," she says.
Drills are valuable, agrees Deputy Chief Mac Venzon of the Reno Police Department - Support Services Division. " By having a plan in place, employees are not left to determine what they should do; rather they have rehearsed a response that they will then act in accordance with more quickly."
The end result will be better outcomes, Nixon says. "When a crisis occurs, logic and rational thinking will not be sufficient," he says. "People will inevitably rely on what they have been trained to do."
Conduct violence prevention training at least annually, and behavior de-escalation should be "first and foremost," says Lisa Pryse Terry, CHPA, CPP, president of healthcare services and chief of company police at ODS Security Solutions, Richmond, VA, and Raleigh, NC. ODS Security Solutions delivers security services for healthcare, commercial, and government clients.
"Recognition and de-escalation of violent behavior is an essential tool for healthcare providers," Terry says.
. Work with your local law enforcement.
Most law enforcement agencies are willing to come to your facility and perform a "security survey," Bray says. "We can't guarantee you'll be 100% crime-free, but we can offer suggestions about how to make it less inviting for a criminal," he says.
Police can offer suggestions on how to control access to facility, Venzon says." By controlling access to back offices, should an assailant present himself, there is a better chance at minimizing the damage if movements are controlled," he says.
An added advantage of a security survey is that managers meet police and might be more inclined to call, Venzon says. "All too often we find that citizens feel like they would be bothering the police if they report something that does not reach the level of criminal activity, but just doesn't seem right," he says.
In Reno, the shooter pulled a shotgun from his vehicle and walked from the parking lot to the third floor, passing several patients and visitors, but nothing was reported until he started shooting, Venzon says." As police, we need the public as our eyes and ears so that we can react as quickly as possible to try and minimize the damage and tragedy caused by an active assailant," he says.
. Be vigilant.
"When you notice someone that is not acting right, or makes statements that might seem out of place and dangerous in nature, let someone know," Venzon says. "It is my experience that many active assailants have let on that they are planning something terrible."
You can notify local law enforcement or mental health professionals, if a person seems to be making statements that are concerning, he says. "Further, being keenly aware of people that may pose a threat, and notifying someone - law enforcement, mental health professionals, or even family members - that something is not right with the individual will go a long way in attempting to prevent such tragedies," Venzon says.
Preparation is vital, Peek-Asa emphasizes. "The most effective approach is to focus on prevention: identifying any potentially violent situations early and having a structure in place about how to handle them," she says.
- National Institute for Prevention of Workplace Violence. Prevention outweighs reaction. "Get the Facts." 2013 The Workplace Violence Fact Sheet. Accessed at http://www.workplaceviolence911.com/node/975.
- Society for Human Resource Management. SHRM survey finding: Workplace violence, February 2012. Accessed at www.shrm.org/surveys.
- Restrepo T, Shuford H. Violence in the Workplace, NCCI Research Brief, January 2012.
- The Center for Personal Protection and Safety has developed training modules, videos, and evaluation tools on workplace violence prevention ("Flashpoint - Healthcare") and Active Shooter Response ("Shots Fired - Healthcare"). Web: www.cppssite.com.
- The National Institute for Occupational Safety and Health (NIOSH) has launched an online training program, complete with free continuing education. The course describes risk factors for patient assaults as well as co-worker aggression. The course offers intervention strategies to help staff prevent a situation from escalating. Case studies illustrate appropriate ways to respond. NIOSH also provides checklists and sample incident reports. Web: www.cdc.gov/niosh/topics/violence/training_nurses.html.
- The National Institute for Prevention of Workplace Violence has specific methods, tools, and processes on workplace violence. Web: www.WorkplaceViolence911.com. Sign up for a complimentary subscription to "The Workplace Violence Prevention eReport," which is published online every other month, at
- Occupational Safety and Health Administration's Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Web: http://1.usa.gov/1hsgTin.