The danger to healthcare providers is escalating as violent incidents move from the streets into the medical setting. Unfortunately, we are now all too familiar with the recent occurrence in the parking lot of a Chicago hospital. While that particular act of violence took place outside the four walls of the facility, the ED and its surrounding departments were deeply impacted.

This again brings to light a need in our industry to do the best we can to prepare our teams for violent incidents. Most at risk is the emergency department due to its ease of access. Emergency Department violence has become a public health menace, and reducing it requires that we mitigate the potential for harm whenever possible.

In this post – part two of our three-part series – we discuss seven steps hospital administrators and emergency department staff can take to create a safer work environment for patients, visitors, and staff.

Step 1. Establish a Zero Tolerance Policy

Hospitals need to establish a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats, and related actions.

Establishing a workplace violence policy begins with hospital administrators making a firm commitment to creating an environment that places equal importance on the safety of employees and patients alike.

The CDC says such commitment provides the motivation and resources to deal effectively with workplace violence, and recommends that the policy:

  • Demonstrate concern for employees’ emotional and physical health and safety;
  • Exhibit equal commitment to the safety and health of workers and patients;
  • Assign responsibility for the various aspects of a workplace violence prevention program to make sure that all managers, supervisors, and employees understand their obligations;
  • Allocate appropriate authority and resources to all responsible parties;
  • Maintain a system of accountability for involved managers, supervisors, and employees;
  • Establish a comprehensive program of medical and psychological counseling and debriefing for employees experiencing or witnessing assaults and other violent incidents;
  • Support and implement appropriate recommendations from safety and health committees.

Step 2: Conduct a Worksite Violence Hazard Analysis

A worksite hazard analysis, another necessary step, involves a methodical, commonsense look at the emergency department to find existing or potential hazards for workplace violence. It consists of reviewing procedures or operations that contribute to risks and specific areas where hazards may develop. A hazard analysis should include:

  • Analyzing and tracking records
  • Screening surveys
  • Analyzing workplace security

Distribute the screening survey to all ED personnel to get their input on the potential for violent incidents and identify or confirm the need for improved security measures.

Step 3: Develop a Hazard Prevention Plan

After identifying hazards, hospital administrators in tandem with emergency department management should develop a plan to prevent or control violent incidents.

The OSHA document, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (PDF), can serve as a helpful reference for this purpose.

It suggests that at a minimum, a workplace violence prevention program should:

  • Outline a comprehensive plan for maintaining security in the workplace, which includes establishing a liaison with law enforcement personnel and others who can help identify ways to prevent and mitigate workplace violence;
  • Assign responsibility and authority for the program to individuals or teams with appropriate training and skills;
  • Ensure that adequate resources are available and that responsible parties develop expertise in workplace violence prevention;
  • Set up a briefing as part of the initial effort to address issues such as preserving safety, supporting affected employees, and facilitating recovery.

Step 4: Provide Safety and Health Training for Hospital Personnel

Training guarantees that the ED staff is aware of potential security threats and knows how to protect themselves and their co-workers through established policies and procedures.

Recognize Signs of Emergency Room Violence

An important aspect of training consists of recognizing signs of violence. According to Dr. Phil Parker, Group Medical Officer, SCP, signs of emergency room violence fall under two primary categories: behavioral, and historical or epidemiological.

Behavioral signs include:

  • Posture. Does the patient appear tense, have clenched fists, or a flushed appearance?
  • Speech. Is the patient's speech loud, threatening, insistent, or rapid?
  • Motor. Is the patient restless, pacing, or easily startled?

Historical and epidemiological signs include a history of violence, especially that which is frequent, serious, or unprovoked.

These signs also depend on the type of diagnosis, such as substance abuse, acute psychoses, acute organic brain syndrome, personality disorders, or partial complex seizures.

Security Guard Training

Training hospital security guards to national standards is another essential part of a comprehensive program. Some areas to consider are:

  • Verbal de-escalation/crisis intervention
  • Security equipment training
  • Active shooter response
  • Use of force and restraints
  • Report writing and incident reporting
  • Bomb threat response
  • Less-lethal weapons training
  • State required training, if applicable
  • Firearms training

Step 5: Encourage Incident Reporting

In recent years, OSHA has aggressively investigated complaints of workplace violence against healthcare workers, typically in emergency departments and mental health departments of hospitals.

It encourages employees to report incidents promptly and suggest ways to reduce or eliminate risks. Also, hospital administration and management must ensure that employees who report or experience incidents not face reprisals.

Step 6: Maintain Records to Assess Risk, Measure Progress

According to OSHA guidelines, recordkeeping and evaluation of the ED violence prevention program are necessary to determine its overall effectiveness and identify any deficiencies or needed changes.

Important records include:

  • OSHA log of work-related injury and illness (OSHA Form 300);
  • Any new work-related injury that results in death, days away from work, days of restriction or job transfer, medical treatment beyond first aid, and losds of consciousness or significant injury diagnosed by a licensed health care professional;
  • Medical reports of work injury and supervisors' reports for each recorded assault. These should describe the type of assault, such as a sudden, unprovoked attack or patient-to-patient altercation, who was assaulted, and all other circumstances of the incident.

Records should also include:

  • A description of the environment or location, potential or actual cost, lost work time that resulted, and the nature of injuries sustained;
  • Incidents of abuse, verbal attacks, or aggressive behavior that may be threatening;
  • Information on patients with a history of past violence, drug abuse, or criminal activity recorded on the patient's chart;
  • Documentation of minutes of safety meetings, records of hazard analyses, and corrective actions recommended and taken.

Step 7: Secure the Facility

The engineering department, along with security personnel, should enhance building security with cameras (HIPAA guidelines apply, so cameras can’t be in patient rooms but could be in main waiting rooms, etc.), metal detectors, controlled access, panic buttons, and similar measures.


The reduction of violence in the ED requires that we make violence personally and culturally intolerable. The only way to achieve the goal of optimal patient care is by protecting everyone — patients, visitors, and healthcare workers — against violent acts. Employing these seven steps can help improve the safety of your emergency department and hospital at large. Our hope is that you never have to encounter workplace violence in the ED; but as ACEP President, Dr. Vidor E. Friedman recently stated in an editorial in ModernHealthcare about the incident in Chicago, “…never has the adage been more true: an ounce of prevention is worth a pound of cure.”

This post is the second in a three-part series that addresses the growing trend toward violence in the emergency department. The first post provided a clear understanding of why violence occurs, statistics on when and how it’s reported, and what providers and hospital administration can do to make the environment safer for their teams. Post three will provide guidance on how to safely restrain a patient undergoing a violent episode.