In 2008, three people—including a nurse, another hospital employee, and a visitor—were killed in a shooting spree at Doctors Hospital in Columbus, Ga. In February 2010, a gunman walked into the emergency department of Scotland Memorial Hospital in Laurinburg, N.C., and shot two patients before being subdued by police. Most recently, the son of a patient at Johns Hopkins Hospital in Baltimore shot and wounded orthopaedic surgeon David B. Cohen, MD, before barricading himself in a room and killing his mother and himself.

According to a Sentinel Event Alert issued by The Joint Commission earlier this year, hospitals and other healthcare institutions are seeing increased rates of violent crime, including assault, rape, and homicide. The Joint Commission’s Sentinel Event Database lists 256 such incidents since 1995, but the organization believes those numbers to be significantly underreported. In addition, violent crimes are consistently among the top 10 types of sentinel events reported to The Joint Commission each year.

Some incidents, such as the one involving Dr. Cohen, are sudden, tragic, and almost certainly unpredictable and therefore unavoidable. Additionally, not all situations involving angry patients end in violence. But because the potential for violence exists in almost every workplace, including healthcare settings, taking certain proactive steps on both staff and institutional levels may help to minimize risk while maintaining an open and nurturing environment conducive to patient care.

Key among those steps are observation and communication. Healthcare staffers—including physicians and nurses—need to be aware of their surroundings and able to identify potentially explosive situations before they escalate into actual violence. Additionally, keeping lines of communication open on all levels is important, beginning with the moment a patient first walks into an office, and culminating in close working relationships among providers, administration, and security staff.

“Generally, if someone is angry and allowed to express that anger, listening and acknowledging the emotion should be the first response,” says Kenneth M. Singer, MD, a member of the AAOS Communication Skills Mentoring Program (CSMP) project team, which conducts interactive workshops to help orthopaedic surgeons improve their communication skills.

Listen and acknowledge
Dealing with an angry patient is just one aspect of the CSMP course, but it is an important one. Dr. Singer stresses the need for physicians to build a trusting relationship with the patient and family members early on, to minimize the risk of a communication breakdown that could spiral out of control.

“A physician should have a system within the office to make people (staff and patients) feel important. An equal relationship should exist between the patient and the physician, as opposed to one in which one person is in charge and another is subservient,” he says. “Throughout the patient care relationship, trust equity needs to be built up so if a problem arises, you’re less likely to have an anxious patient. It’s also crucial to adequately inform patients about what’s going to happen to them and what their expectations should be. Often the anger that a patient expresses is fear based—he or she is frightened because of uncertainty with his or her medical condition. Things have not gone well, or as expected, and the frustration mounts.”

If an interaction with a patient becomes emotionally charged, Dr. Singer recommends allowing the patient to express his or her anger, followed by the provider’s acknowledgement of that anger with empathy and a paraphrasing of the patient’s comments. Paraphrasing enables the patient to understand that his or her issues are being heard and understood.

“Generally we find that this technique will result in defusing the anger over time,” explains Dr. Singer. “At that point, attention should be directed toward dealing with the original problem.

“In addition, we find that silence can be particularly helpful, because an angry patient or family member will not allow silence to remain for very long, and he or she will continue to talk,” he continues. “That’s the goal—to allow the person to continue to vent in an atmosphere that is conducive to being heard and understood. We emphasize empathy (the ability to relate to the person’s experience as an equal and without judgment), which is not the same as sympathy.”

The next level
In some cases, attempts to defuse someone’s anger may be unsuccessful. Verbal clues such as threats may indicate that a patient or family member is close to losing control and are relatively easy to identify, but nonverbal cues, including erratic behavior and an increasing degree of physical agitation, may be less obvious and potentially more important.

According to Dr. Singer, if a physician has any suspicion that a situation may turn violent, he or she should contact hospital security or law enforcement as soon as possible. Raymond J. Samoska, manager of operations for public safety and parking at Advocate Christ Medical Center in Oak Lawn, Ill., agrees.

“If you see some of that low-level agitation and it’s not addressed immediately, it’s likely to escalate,” says Mr. Samoska. “If a healthcare provider notices that a person is getting verbally abusive or physically agitated, the provider needs to try verbal de-escalation techniques and possibly give security a call just to make sure help is in the area.”

Advocate Christ is a Level 1 Trauma Center located just outside of Chicago. Two years ago, the hospital instituted a program designed to proactively address the growing issue of violence in the healthcare setting. The multiprong initiative includes security staff
deployed in a “zone method”—similar to a police officer’s beat—which enables officers to build relationships with the medical staff within their zone, as well as gain greater familiarity with the zone itself.

Additionally, a team of 15 select security officers trains with local police to deal with high-risk scenarios such as gunfire or a hostage situation. In an emergency, specific zones or even the entire hospital campus can be electronically locked down. Future plans include adding a canine unit to assist with security, as well as tracking, drug-sniffing, and community outreach.

Working together
The security program extends beyond tactical efforts; medical personnel and visiting physicians are offered regular educational sessions in workplace violence prevention. Staff is trained to spot the warning signs of impending violence and to use de-escalation techniques. By request, training can be customized to fit the needs of the various hospital departments—an important factor because, despite the need for safety, most hospitals don’t want to be perceived as fortresses.

“We want to maintain a welcoming, heal-and-be-quiet atmosphere,” Mr. Samoska explains. “At the same time, hospitals need to be safe places. That was part of the reason Advocate Christ adopted the zone patrolling method. Our officers have been trained in customer service techniques, so if customer service is needed, they can assist, but if the security aspect is required, they are available to provide that as well.”

The Joint Commission recommends that medical staff and security work together to evaluate the facility and determine an appropriate balance. At Advocate Christ, security personnel meet with the president of the medical staff on a monthly basis to address any concerns that may have arisen.

“Regular meetings are great, because I can get a heads-up on problems before they become larger issues,” says Mr. Samoska. “I can sit down with the medical staff and work on solutions. In the past, we had very little contact with the medical personnel, but now we’re sending people to speak at their staff meetings and we’re keeping them up to date on what we’re doing. I think that’s made a big difference in how healthcare providers feel about their safety on the campus.

“The emergency department doctors in particular have been very enthusiastic about the improvements underway,” he continues. “I would have to say our medical staff is very supportive of the changes we’ve made. They’ve seen the patient volumes grow; they’ve seen the potential for incidents to occur. In the last year, doctors have not only been more willing to talk with security staff about their concerns, but they have begun to seek us out to discuss how we can help address those issues.”

If physicians have concerns about security, Mr. Samoska recommends that they begin building a relationship with the emergency management and public safety departments. Physicians, he understands, may often be too busy to attend seminars, but that doesn’t mean they have to remain in the dark.

“We try to publicize all the things that we do,” he says. “At a minimum, we can forward physicians our slide presentations or point them to the proper Web site where they can find the appropriate information.”

“There are many steps that a physician can take in the context of his or her office setting to help reduce incidents of violence,” agrees Dr. Singer. “Like so many other things, it’s better to prevent the situation than to have to deal with it.”

For more information on the CSMP or to schedule an interactive session at your practice, state society meeting, or residency program, visit www.aaos.org/csmp

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Joint Commission suggested actions
The following are suggested actions that health care organizations can take to prevent assault, rape, and homicide in the health care setting. Some of these recommendations are detailed in the Healthcare Risk Control (HRC) issue on “Violence in Healthcare Facilities” (published by ECRI Institute).

1. 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 health care facility, and survey employees on their perceptions of risk.
2. Identify strengths and weaknesses and make improvements to the facility’s violence-prevention program. (The HRC issue on “Violence in Healthcare Facilities” includes a self-assessment questionnaire that can help with this.)
3. Take extra security precautions in the Emergency Department, especially if the facility is in an area with a high crime rate or gang activity. These precautions can include posting uniformed security officers and limiting or screening visitors (for example, wanding for weapons or conducting bag checks).
4. Work with the human resources (HR) department to make sure it thoroughly prescreens job applicants, and establishes and follows procedures for conducting background checks of prospective employees and staff. For clinical staff, the HR department also 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.
5. Confirm that the HR department ensures that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction.
6. Require appropriate staff members to undergo training in responding to patients’ family members who are agitated and potentially violent. Include education on procedures for notifying supervisors and security staff.
7. Ensure that procedures for responding to incidents of workplace violence (eg, notifying department managers or security, activating codes) are in place and that employees receive instruction on these procedures.
8. Encourage employees and other staff to report incidents of violent activity and any perceived threats of violence.
9. Educate supervisors that all reports of suspicious behavior or threats by another employee must be treated seriously and thoroughly investigated. Train supervisors to recognize when an employee or patient may be experiencing behaviors related to domestic violence issues.
10. Ensure that counseling programs for employees who become victims of workplace crime or violence are in place.
    Should an act of violence occur at your facility—whether assault, rape, homicide or a lesser offense—follow up with an appropriate response that includes:
11. Reporting the crime to appropriate law enforcement officers.
12. Recommending counseling and other support to patients and visitors to your facility who were affected by the violent act.
13. Reviewing the event and making changes to prevent future occurrences.

© The Joint Commission, 2010. Reprinted with permission.