Fatal assault on physician highlights violence risk

Violence prevention can reduce incidences

The fatal assault of a physician at a California psychiatric facility once again has highlighted the need for strong workplace violence prevention programs at hospitals.

In fact, California is the only state that requires a violence prevention program at hospitals — a law that has been largely successful in promoting violence prevention, training, and better reporting, according to a researcher studying the issue.

John George Psychiatric Pavilion in San Leandro, a locked, inpatient facility, cares for patients in acute crisis — those deemed a possible danger to themselves or others.

For months, nurses at John George complained to Cal-OSHA (the California Occupational Safety and Health Administration) about inadequate security at the county-run facility, which has suffered from budget deficits and staffing problems.

In April, Cal-OSHA cited the facility for failing to report two serious assaults on nurses and for failing to sufficiently implement an injury and illness prevention program. The hospital is contesting the citations.

On Nov. 20, John George staff became concerned when they saw a new patient wandering around with a partially completed medical form. Soon after, internist Erlinda Ursua, MD, was found dead in a private exam room; she had been conducting a medical history and physical on the patient. Ursua had been beaten in the head and strangled, according to reports from the patient’s arraignment.

"It’s a longstanding issue. We’ve been trying to get them to improve the employee and staff patient safety there for a while," says Bradley Cleveland, communications and research director of Service Employees International Union (SEIU) Local 616. John George is a part of Alameda County Medical Center.

"I don’t think our facilities are unique in terms of the kinds of incidents that may occur," he says. "I think at these kinds of facilities, you have a potential danger of assaults on staff. They have to have systems in place to address these potential threats."

Hospitals in California are required to have a violence prevention program to receive their state license. When Corinne Peek-Asa, MPH, PhD, associate professor of occupational health at the University of Iowa’s Injury Prevention Research Center in Iowa City, surveyed 16 hospitals as a part of a research project on the violence prevention law, she found they had all complied.

The content of those programs differs widely. But since the law was implemented in 1995, the number of violent events at hospitals has decreased — even with an improvement in reporting, she says. Hospitals could make even more progress if they analyzed their violent incidents to look for opportunities for improvement, she says.

"Even though every facility that we visited had a reporting system, and some of them had multiple reporting systems, the reporting system was never used to form prevention strategies. That was the missing link," says Peek-Asa, whose research is sponsored by the National Institute for Occupational Safety and Health and conducted in conjunction with the California Department of Health Services.

The John George case illustrates the challenges for facilities working with troubled patients and the importance of security and violence prevention policies.

John George had a performance improvement task force that was working on the issue of security when the incident occurred. Last summer, the facility underwent a survey and received accreditation from the Joint Commission on Accreditation of Healthcare Organizations. John George had stated that it would work on lowering patient assaults on staff and reducing lifting injuries as part of its performance improvement plan, says Cleveland.

Meanwhile, in April, Cal-OSHA had received six written complaints and numerous phone calls from John George employees about the risk of patient-on-staff violence, says Cal-OSHA spokesman Dean Fryer. Cal-OSHA sent John George a letter asking the hospital to explain how it planned to reduce the hazard, but didn’t get a response until the agency launched a formal investigation in late May.

"During our interview process, we found that there were assaults against nurses on two occasions," he says.

"On Dec. 25, 2002, a nurse was stabbed by a patient. It was a nonfatal injury. On April 9, there was another assault on a nurse who suffered a fractured nose. We had not received notice of either one of those attacks, which was required," Fryer explains.

Cal-OSHA issued citations and fines totaling $30,000. The agency also recommended that John George install security cameras, hire armed peace officers, and implement a policy that staff should never be alone with a patient. The hospital appealed the citations, which meant it wasn’t required to make changes, he points out.

"To our knowledge, none of those suggestions were implemented," Fryer says. "We’re now looking at what steps they may have taken since our last citation."

Since Ursua’s death, computer flags have been added to all records of patients with a history of assaultive behavior, according to a medical center spokeswoman.

An attendant will be present with medical staff during histories and physicals. The facility also hired sheriff’s deputies in addition to private security staff, so there will be a staff of five security personnel on each shift, the spokeswoman said.

Despite those changes, a patient committed suicide at the facility in early December.

Staffing shortages and financial constraints can contribute to a stressful environment, says Peek-Asa. "That makes [violence] prevention programs even more crucial," she says.

Peek-Asa and her colleagues are planning to study violence prevention in other states, to provide a comparison with the California experience.

One of the key aspects of violence prevention is training, a requirement of the California law, she notes. "Every hospital we went to had training programs. The content and the delivery of those programs varied dramatically. We definitely need to take a better look at what the best delivery system is."

Training needs to continue to be relevant and effective to keep the issue in the minds of employees, she says. "The potential for threat is always there. I think you sort of get inured to it when it’s something you see every day," Peek-Asa says. "It’s important just to keep the word out there that there are strategies that can help reduce that threat."

Staffing also can affect worker safety, says Cleveland. He notes that California’s minimum staffing ratios went into effect in January. "That alone could have a positive effect on the employee safety issue," he says.