Healthcare Violence Is Increasing; Is Your Hospital Prepared?

The season finale of ABC's Grey's Anatomy two weeks ago depicted a distraught husband firing his gun as he walked the halls of Seattle Grace, killing and critically wounding patients, providers, and even security personnel.

The two-hour Columbine-like massacre, while dramatic, served as another reminder that healthcare facilities, which increasingly are treating sicker and poorer patients, are also rife with all sorts of emotion, both obvious and hidden.

That fact was validated yesterday when the Joint Commission issued a Sentinel Event Alert on violence in the healthcare setting, saying that there have been "significant increases in reports of assault, rape, and homicide, with the greatest number of reports in the last three years."

A Joint Commission spokeswoman said yesterday that the TV show's violence was not the reason for issuing the alert. Rather, she said, the reason was the number of violent events that are occurring in real life: Specifically, "36 incidents in 2007, 41 in 2008, and 33 in 2009," according to the Commission's Sentinel Alert statement. According to the commission's Web site, there were 20, 25, 24, 4, and 6 incidents each year in 2006, 2005, 2004, 2003 and 2002.

The Commission database has 256 such reports since 1995, which it says are significantly below the actual number of incidents because of under-reporting of violent crimes by healthcare institutions.

The Commission database has 256 such reports since 1995, which it says are significantly below the actual number of incidents because of under-reporting of violent crimes by healthcare institutions.

The alert did not indicate how many violent incidents have involved healthcare settings so far in 2010, but clearly there have been several well-publicized incidents across the country.

In April, a man who thought doctors had implanted a tracking chip during his appendectomy shot and killed one woman, wounded two others, and then killed himself at a Parkwest Hospital in Knoxville, Tennessee, according to police reports.

In March, an elderly Connecticut cardiac patient allegedly pulled a handgun from his hospital gown and fired, wounding a male nurse in three places at Danbury Hospital, according to newspaper reports.

And there have been others.

The Joint Commission's database found six recurring causes for these criminal events.

1. Issues in leadership were noted in 62% of the events, most notably problems in the areas of policy and procedure development and implementation.
2. Human resources-related factors were noted in 60% of events, such as the increased need for staff education and competency assessment processes.
3. Assessment issues, noted in 58% of events, particularly in the areas of flawed patient observation protocols, inadequate assessment tools, and lack of psychiatric assessment.
4. Communication failures, noted in 53% of the events, in terms of deficiencies in general safety of the environment and security procedures and practices.
5. Physical environment issues, noted in 36% of the events, in terms of deficiencies in general safety of the environment and security procedures and practices
6. Problems in care planning, information management, and patient education were other causal factors identified less frequently.

In its alert, the Joint Commission reminded healthcare providers that "because hospitals are open to the public around the clock every day of the year, securing the building and grounds presents specific challenges since it would be difficult to thoroughly screen every person entering the facility.

"For many reasons, in particular high-traffic areas coupled with high-stress levels – the Emergency department is typically the hardest area to secure, followed by general medical/surgical patient rooms."

In the Joint Commission's alert, Russell L. Colling, a health security consultant based in Salida, CO, and the founding president of the International Association for Healthcare Security and Safety, suggested "layered levels of control" or ways to secure the perimeter of the property through lighting, barriers, fencing, controlling access through entrances, exits, and stairwells and positioning nurses stations.

But it isn't just patients or their loved ones who can pose a threat to hospital staff. "Administrators must be alert to the potential for violence to patients by healthcare staff members," the Joint Commission alert said. "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."

Health providers sometimes do deliberately harm patients, either by assaulting them or administering medications or treatments. This "presents a considerable threat to institutions, even when the patient is unable to identify the responsible person."

The commission recommends performing criminal background checks on job candidates, especially those "who are to be placed in high risk areas, such as the ED, obstetrics, pediatrics, nursery, home care, and senior care settings."

The commission suggests that hospitals take the following actions minimize violent incidents:

• 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 healthcare facility, and survey employees on their perceptions of risk.
• Identify strengths and weaknesses and make improvements to the facility's violence-prevention program.
• Take extra security precautions in the Emergency Department, especially if the facility is in an area with a high crime rate or gang activity, such as having uniformed security officers, and limiting or screening visitors for weapons.
• Make sure the HR department prescreens job applicants and for clinical staff, and 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, check the clinician's information, which includes professional competence and conduct.
• Confirm that the HR department ensures that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction.
• Require appropriate staff members to undergo training in how to respond to agitated, potentially violent family members and include procedures for notifying supervisors and security staff.
• Ensure that notification procedures or code activations are in place and that employees are properly trained in their use.
• Encourage employees and other staff to report incidents or threats of violent activity. Train supervisors to recognize when an employee or patient is exhibiting behaviors related to domestic violence issues.
• Ensure that counseling programs for employees who become victims of workplace crime or violence are in place.
• If a violent act does take place, report the crime to law enforcement, recommend counseling and support to patients and visitors affected, review the event and make changes to prevent occurrences.