Emotionally-charged situations where patients and family members are fearful and lack control may increase the potential for violence perpetrated against hospital staff in the emergency department. In addition, the event that brought the patient to the emergency department could involve crimes, weapons, drugs and alcohol, or violence. These external factors could put emergency department staff at an increased risk of workplace violence. Although anyone working in a hospital may become a victim of violence, staff who have direct contact with patients are at higher risk.
The effects of violence can range in intensity and include minor or serious physical injuries, temporary or permanent physical disability, psychological trauma, and even death.
The individual risk factors for violence vary from hospital to hospital depending on factors such as location, size, and type of care provided. Some common risk factors for hospital violence include the following:
- Working directly with patients or visitors who have a history of violence, abuse drugs or alcohol, and/or have access to firearms, knives, or other weapons;
- Working when understaffed;
- Long waits for service;
- Overcrowded, uncomfortable waiting rooms;
- Working alone;
- Poor environmental design;
- Inadequate security;
- Lack of staff training and policies for preventing and managing crises with potentially volatile patients;
- Unrestricted movement of the public; and
- Poorly lit corridors, rooms, parking lots, and other areas.
Recognized Controls and Work Practices
- Establishing a Workplace Violence Prevention program to address the risk of violent patients and that includes the following elements:
- Management Commitment to the Workplace Violence Prevention Program
- Employee Participation
- Worksite Analysis
- Hazard Prevention and Control
- Safety and Health Training
- Recordkeeping and Program Evaluation
- Implementing engineering controls, such as:
- Designing of the waiting room to reduce tension from overcrowding.
- Bolting down furniture.
- Securing other items that could be used as weapons, such as phones, fire extinguishers, lamps, etc.
- Installing concealed panic buttons in the emergency department, on staff, and at the check-in area, that can be pushed for emergency help. These buttons could notify hospital security as well as directly reach the local Police Department.
- Installing and maintaining improved lighting and video surveillance.
- Using an escort or buddy system.
- Limiting access to ED area and personnel, by implementing:
- A waiting room area with controlled access to emergency area, where patients need to be buzzed in by receptionist from a secure door.
- Emergency department exits that exit out only, so individuals from outside cannot access the emergency department unless they enter through the waiting room area.
- Training staff to recognize and de-escalate potentially violent situations and patients, to be alert for potential violence and suspicious behavior and report it, and to provide intervention measures including verbal, social, physical, and pharmacological interventions where feasible.
- Providing adequate staffing levels, with experienced clinicians on each shift.
- Using of metal detectors.
- Providing a "secure" room for patients identified to be violent. This room could include controls such as:
- Video camera surveillance,
- Visual surveillance (e.g., through a window),
- Door locks,
- Locked cabinets,
- Furniture and equipment attached to the floor so patients cannot throw them at employees, and
- Laying out the room to help ensure easy exit for workers.
OSHA emphasizes that the controls discussed here do not represent the full array of controls that would comprise an effective Violence Prevention Program. For more information, please see Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. OSHA Publication 3148, (2016) and other documents referenced below.
Warning Signs of Increasing Anger/Violence include:
- Pacing and/or restlessness
- Clenched fists
- Increasingly loud speech
- Excessive insistence
- Threats and cursing
For additional information on Workplace Violence Prevention Program see Hospital-wide Hazards - Workplace Violence.
- Workplace Violence - Prevention Programs. OSHA Safety and Health Topics Page.
- Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. OSHA Publication 3148, (2016).
- Worker Safety in Hospitals: Caring for our Caregivers. OSHA.
- Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence. OSHA Directive CPL 02-01-058 [CPL 02-01-052], (January 10, 2017).
- Inspection Guidance for Inpatient Healthcare Settings. (June 25, 2015). OSHA memorandum establishing guidance for inspections conducted in inpatient healthcare settings.
- Violence Occupational Hazards in Hospitals. U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2002-101, (April 2002).