Hospital shooting incident highlights toll of everyday violence in healthcare
November 1, 2013
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Hospital shooting incident highlights toll of everyday violence in healthcare
Apt held Molotov cocktails, rambling notes, pile of pills
Special Report: Facing down the threat of hospital violence
Navy Yard. Newtown, CT. Aurora, CO. In these mass shooting incidents, the shooter had a history of mental illness. For hospitals, it's all in a day's work to treat patients who may be confused, agitated, or suffering from a psychosis. In this special issue, Hospital Employee Health examines a shooting incident at Western Psychiatric Institute in Pittsburgh. We provide resources on training health care workers and implementing violence-prevention practices. We also highlight another risk factor: Domestic violence that spills over into the workplace.
Also inside: Are you ready for OSHA's Haz Comm standard? By December 1, all employees must be trained on the new labeling and safety data sheet requirements.
It is an all-too-familiar scenario: A mentally ill young man has grievances and a determination to get attention or revenge, or perhaps to carry out a twisted, spectacular suicide. He enters a building and begins shooting, wounding or killing whoever happens to be in his range. Then he dies in a gun battle with police or security officers.
That is essentially what happened on March 8, 2012, at Western Psychiatric Institute and Clinic in Pittsburgh. The case spawned lawsuits, investigations and hospital renovations — and a cautionary tale for other hospitals seeking to minimize the worst kind of workplace violence.
At the same time, the Western Psych shooting also highlights the toll of everyday violence in hospitals, particularly in psychiatric facilities or emergency departments. In 2011, psychiatric and substance abuse hospitals had a rate of violent assaults on staff that was 32 times higher than the average for all industries. Those were incidents that led to days away from work; minor physical assaults and verbal abuse are even more common.
"There’s a crisis mentality when people come into a hospital," says Lisa Pryse, CHPA, CPP, president and chief of company police of ODS Healthcare Security Solutions in Richmond, VA and Raleigh, NC, and president of the International Association of Healthcare Security and Safety. "It’s a microcosm of a city with the potential for violence all the time."
The ultimate act of violence — the "active shooter" — may seem as unpredictable as a lightning strike. But there are conditions that make lightning more likely, or more dangerous, and we take precautions, notes Pryse. Similarly, hospitals can work to avoid and protect against workplace violence, from minor events to deadly ones, she says. (See related story, p. 123.)
"You’ve got to be as educated in human behavior as possible and have some [interventions] in place," she says.
It happened in minutes
On March 8, 2012, 30-year-old John Shick walked out of the rain and into the lobby of Western Psychiatric Institute, his tan-colored trench coat hiding the two semi-automatic handguns he carried and the fanny pack with extra ammunition.
At that moment, Michael Schaab, a 25-year-old geriatric therapist, was returning from a lunch break. Kathryn Leight, 64, sat at the reception desk talking on the telephone and Jeremy Byers, an unarmed security guard, stood nearby, as employees and visitors came in and out of the lobby.
Shick began shooting within 30 seconds of entering the hospital, the district attorney would later tell reporters. A bullet hit Schaab in the aorta, killing him instantly. Leight was shot in the chest and abdomen. He shot two other employees and a hospital visitor — one of them was trying to help Schaab — and then went into a stairwell that led to a second-floor entrance to the garage.
He didn’t have an access card to open the door, so Shick returned to the first floor, where he was accosted by members of the University of Pittsburgh’s Special Emergency Response Team. They shouted at him to stop, but Shick fired at the officers, hitting one in the chest. (The officer was wearing a bullet-proof vest, which deflected the bullet.)
Finally, one of the officers shot Shick three times, killing him and ending the shooting spree. The entire episode had lasted only minutes.
Investigators later found the makings of Molotov cocktail explosives and rambling notes in Shick’s apartment, along with a pile of prescription pills and bottles for a wide variety of maladies.
The questions began literally as soon as the smoke cleared. Who was John Shick? He was a former graduate student at Duquesne University who had been dismissed from the program, and he had frequented doctors in the University of Pittsburgh Medical Center (UPMC) system but was not currently being treated at Western Psych. He had previously been involuntarily committed for psychiatric treatment in New York and Oregon.
What had triggered the shooting? Shick had stopped taking his medication for schizophrenia months before. In the weeks and months before the shooting, he displayed erratic and even threatening behavior and made irrational physical complaints and demands for specific medication and tests. Two physicians had inquired about seeking his involuntary psychiatric commitment, according to court documents.
And, most importantly, could it have been prevented?
Addressing the aftermath
Lawsuits lay out their own answers in stark terms. Shooting victims assert that the University of Pittsburgh, through its physicians, facilities and crisis intervention program, should have initiated involuntary emergency evaluation and treatment of Shick and that Western Psych had inadequate security.
UPMC responded that Shick never made specific threats and hadn’t presented a "clear and present danger to himself or others," requirements for involuntary commitment. (UPMC declined to comment for this article.)
Last year, the Occupational Safety and Health Administration cited two psychiatric hospitals for workplace violence under the "general duty clause," which requires employers to maintain a workplace free of serious, recognized hazards. In one of those cases, a patient attacked a doctor.
But Shick wasn’t actually a patient at Western Psych. And after an investigation into the shooting and other assaults, OSHA declined to cite Western Psych.
The emphasis instead has been on making the psychiatric facility safer. That began with recognition that everyday assaults create an inherently unsafe work environment, says Jane Lipscomb, PhD, RN, FAAN, professor in the University of Maryland School of Nursing and Medicine in Baltimore and an expert in workplace violence. OSHA hired Lipscomb to review workplace violence at Western Psych.
She found that incidents had recently increased, and that the facility had no policy or committee that specifically addressed worker safety or patient-on-staff violence.
"If Western Psych had done a real risk assessment that was focused on staff safety, things may have played out differently," Lipscomb says.
In fact, the union had previously complained that nurses were required to perform security wanding of patients and visitors on the floors. (There were no metal detectors in the lobby.)
"We had a very hard time, even immediately after the shooting, getting resonance on the fact that the day-to-day violence had to be taken very seriously," says Zach Zobrist, MA, executive vice president of SEIU Healthcare Pennsylvania. "It was viewed as part of working at Western Psych.
"What we’ve been saying as a union is that it’s that kind of mentality that leads to more problems," he says. "You need to have the mindset that it does not have to be the norm, even to work in a psychiatric institute, that an employee should get kicked, punched, stabbed with an object, threatened. All of those things had happened on a day-to-day basis."
Becoming more secure
After the shooting, there was no shortage of recommendations for improvements. In a hazard alert letter, OSHA recommended the creation of a labor-management committee to track and review patient-on-staff violence. Western Psych improved communication about incidents of violence and beefed up security.
The Allegheny County district attorney commissioned a security assessment of Western Psych and recommended changes, including more video surveillance cameras, new barriers in the lobby, personal emergency buttons and other enhancements.
In fact, UPMC hired its own security consultants and began investing in better security. Among the changes: An armed security guard is stationed at Western Psych on all shifts, employees enter through a secure entrance with a card swipe, and metal detectors have been placed in UPMC emergency departments in Allegheny County.
"They’re making large architectural changes to revamp the access to the building, the flow and the security operations," says Zobrist. "They included nurses in looking at the blue prints. We were able to include some questions that they hadn’t thought about."
Better communication is essential, he says. "The most important thing is that there be workplace violence assessment and review that’s done by an outside group and shared with frontline staff," he says.
OSHA issued workplace violence prevention guidelines specifically geared toward health care and social services in 2004, and those recommendations still serve as a template. (www.osha.gov/Publications/OSHA3148/osha3148.html) (See box on p. 123.)
Lessons from other shootings
Hospital security experts also have learned lessons from "active shooter" incidents around the country.
"Probably one of the biggest things we learned from Virginia Tech [where a student killed 32 and injured 17 students and faculty in 2007] is the need to have an ongoing threat assessment team in your facility that meets regularly and often," says Pryse. Weekly or bi-weekly is a good goal, she says.
The team should be interdisciplinary, including representatives from human resources, risk management, security, legal, occupational health and other areas, as needed, she says. The minutes are kept confidential, unless they need to be shared for a specific purpose. The meetings are generally brief, lasting about 30 minutes to an hour.
The critical piece, says Pryse, is communication about potential threats. For example, someone may be agitated over a specific incident — such as the death of a loved one — and that anger may escalate when a medical bill or other communication from the hospital arrives. Resolving the billing issue and halting communication can remove a potential instigating factor, Pryse says.
A patient or visitor who exhibits repeated hostile or aggressive behavior may eventually be barred from the hospital, except in the case of a medical emergency. But before that happens, a staff person with a positive relationship with the patient can try to de-escalate situations, conveying both kindness and firmness about expected behavior, Pryse says. "It can be just as simple as having the right person have contact with that individual," she says.
Could the Western Psych shooting have been prevented? "It’s impossible to judge whether anything could have been done to prevent this man from coming in and taking the life of this staff [member]," says Lipscomb.
But she and other experts in workplace violence urge health care employers to take whatever steps they can to prevent all types of violence and to protect staff, patients and visitors if an incident occurs.
[Editor’s note: The description of the shooting was drawn from news reports in the Pittsburgh Post-Gazette and Tribune-Review and from court documents.]
Tips and strategies to prevent violence
Times of risk: Pt transfers, emergency response, mealtimes
An OSHA list of work practices to help prevent incidents of workplace violence in hospitals includes the following key points:
- Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities to expedite investigations.
- Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrences.
- Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary.
- Set up a trained response team to respond to emergencies.
- Use properly trained security officers to deal with aggressive behavior. Follow written security procedures.
- Ensure that adequate and properly trained staff are available to restrain patients or clients, if necessary.
- Ensure that adequate and qualified staff are available at all times. The times of greatest risk occur during patient transfers, emergency responses, mealtimes and at night. Areas with the greatest risk include admission units and crisis or acute care units.
- Institute a sign-in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures.
- Establish a list of "restricted visitors" for patients with a history of violence or gang activity. Make copies available at security checkpoints, nurses' stations and visitor sign-in areas.
- Supervise the movement of psychiatric clients and patients throughout the facility.
- Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.
- Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable. Do not allow employees to enter seclusion rooms alone.
- Determine the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors.
- Establish a system — such as chart tags, log books or verbal census reports — to identify patients and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed.
- Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions).
- Use case management conferences with coworkers and supervisors to discuss ways to effectively treat potentially violent patients.
- For the complete list of prevention strategies and more information in other areas see: OSHA Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers:www.osha.gov/Publications/OSHA3148/osha3148.html.
Free online course on violence prevention
NIOSH provides CEUs, resources for nurses
Training nurses about workplace violence has just become free and easy — with information literally at their fingertips. The National Institute for Occupational Safety and Health (NIOSH) has launched an online training program, complete with free continuing education units. (www.cdc.gov/niosh/topics/violence/training_nurses.html)
There has been an unmet demand for information about preventing workplace violence, says Dan Hartley, EdD, Workplace Violence Prevention Coordinator in NIOSH's Division of Safety Research in Morgantown, WV. Within 10 days of the release of the course, almost 300 people had completed it for CEUs, he says.
Although the health care industry has the highest rate of occupational injury from assaults that require days away from work, many nurses have never had any specialized training, he says.
"Health care professionals could go their entire career without having any workplace violence prevention training," he says.
The course describes risk factors for patient assaults as well as co-worker aggression, such as bullying. For example, it notes that people with a major mental disorder and/or substance abuse problem have a significantly greater likelihood of displaying violent behavior.
Nurses can gauge the potential risk of violence using assessment tools, NIOSH says. Sample tools are provided with the training.
Perhaps most importantly, the workplace violence course offers intervention strategies to help nurses prevent a situation from escalating to violence. Case studies illustrate appropriate ways to respond to different scenarios.
NIOSH also provides additional resources, including checklists and sample incident reports.
In the next couple of years, NIOSH plans to add content to the course, including specific modules for the emergency department, psychiatric units and nursing homes, Hartley says.
Employers can adapt the course to incorporate into their own employee training, adding hospital-specific policies and forms, says Hartley.
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