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A Sentinel Event In Healthcare

Posted Jun 03 2010 12:00am

The Joint Commission reports that health care facilities are being confronted with steadily increasing rates of crime, including assault, rape and murder. The following is reported by the Joint Commission:

Preventing violence in the health care setting

Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide. As criminal activity spills over from the streets onto the campuses and through the doors, providing for the safety and security of all patients, visitors and staff within the walls of a health care institution, as well as on the grounds, requires increasing vigilant attention and action by safety and security personnel as well as all health care staff and providers.

While there are many different types of crimes and instances of violence that take place in the health care setting, this Sentinel Event Alert specifically addresses assault, rape or homicide of patients and visitors perpetrated by staff, visitors, other patients, and intruders to the institution. The Joint Commission’s Sentinel Event Database includes a category of assault, rape and homicide (combined) with 256 reports since 1995 – numbers that are believed to be significantly below the actual number of incidents due to the belief that there is significant under-reporting of violent crimes in health care institutions. While not an accurate measure of incidence, it is noteworthy that the assault, rape and homicide category of sentinel events is consistently among the top 10 types of sentinel events reported to The Joint Commission. Since 2004, the Sentinel Event Database indicates significant increases in reports of assault, rape and homicide, with the greatest number of reports in the last three years: 36 incidents in 2007, 41 in 2008 and 33 in 2009.

Of the information in the Sentinel Event Database regarding criminal events, the following contributing causal factors were identified most frequently over the last five years:

* Leadership, noted in 62 percent of the events, most notably problems in the areas of policy and procedure development and implementation.
* Human resources-related factors, noted in 60 percent of the events, such as the increased need for staff education and competency assessment processes.
* Assessment, noted in 58 percent of the events, particularly in the areas of flawed patient observation protocols, inadequate assessment tools, and lack of psychiatric assessment.
* Communication failures, noted in 53 percent of the events, both among staff and with patients and family.
* Physical environment, noted in 36 percent of the events, in terms of deficiencies in general safety of the environment and security procedures and practices.
* Problems in care planning, information management and patient education were other causal factors identified less frequently.

Identifying high risk areas

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. “A key to providing protection to patients is controlling access,” explains Russell L. Colling, M.S., CHPA, a health care security consultant based in Salida, Colo., and the founding president of the International Association for Healthcare Security and Safety. “Facilities must institute layered levels of control which includes securing the perimeter of the property through lighting, barriers, fencing; controlling access through entrances, exits, and stairwells; and positioning nurses stations, to name a few of the steps that organizations need to take.”

Perpetrators of violence to patients

While controlling access to the facility is imperative and ongoing surveillance of the grounds is a necessity, administrators must be alert to the potential for violence to patients by health care staff members. 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. Though it is a less common scenario, health care workers who deliberately harm patients by either assaulting them or administering unprescribed medications or treatments, present a considerable threat to institutions, even when the patient is unable to identify the responsible person. These situations point directly to the critical role human resources departments have in developing and following through on hiring, firing and disciplinary practices (which should be supported by management), and in performing thorough criminal background checks on all new hires. Since criminal background checks are costly, at a minimum, organizations may want to conduct criminal background checks on job candidates who are to be placed in high risk areas, such as the ED, obstetrics, pediatrics, nursery, home care and senior care settings.

Prevention strategies

There are many steps that organizations can take to reduce the risk of violence and prevent situations from escalating. “Each hospital or institution must determine for itself how to protect the environment, and that is accomplished by doing a risk assessment and identifying all the things that can go wrong and how to address them with the least inconvenience and resources,” Russell Colling says. “The most important factor in protecting patients from harm is the caregiver – security is a people action and requires staff taking responsibility, asking questions, and reporting any and all threats or suspicious events.” Colling recommends that organizations adopt a zero tolerance policy and establish strong policies mandating staff to report any real or perceived threats. “The roots of violence need to be investigated and evaluated beginning at the unit level. Nurses and other health care staff should question the presence of all visitors in patient rooms and not assume that someone is a family member or friend,” says Colling.

ECRI Institute, an independent nonprofit organization that researches best practices to improve patient care, publishes a journal for health care risk managers called Healthcare Risk Control (HRC) (1). The September 2005 issue has a focus on “Violence in Healthcare Facilities” that discusses strategies for: preventing violent incidents; managing situations to prevent escalation; and enhancing the physical security of institutions through traditional measures (e.g., fences, locks, key inventory, strengthened windows and doors) and electronic measures (e.g., metal detectors, handheld security wands, video surveillance, alarms, access controls systems that require codes or cards). The publication also outlines:

* Techniques for identifying potentially violent individuals
* Violence de-escalation tools that health care workers can employ
* Violence management training
* Conducting a violence audit
* Conducting a violence assessment walk-through
* Responding in the wake of a violent event

In addition, the Occupational Safety and Health Administration offers advisory guidelines for preventing patient-to-staff workplace violence in the health care setting. (2) In January 2007, the International Association for Healthcare Security and Safety issued its first set of Healthcare Security: Basic Industry Guidelines, a resource for health care institutions in developing and managing a security management plan, addressing security training, conducting investigations, identifying areas of high risk, and more. (3)

Existing Joint Commission requirements

The Joint Commission’s Environment of Care standards require health care facilities to address and maintain a written plan describing how an institution provides for the security of patients, staff and visitors. Institutions are also required to conduct risk assessments to determine the potential for violence, provide strategies for preventing instances of violence, and establish a response plan that is enacted when an incident occurs. The Rights and Responsibilities of the Individual standard 01.06.03 provides for the patient’s right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.

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 HRC issue on “Violence in Healthcare Facilities.”

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 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. (4)
7. Ensure that procedures for responding to incidents of workplace violence (e.g., 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 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.


1 ECRI Institute: Violence in Healthcare Facilities. Healthcare Risk Control, September 2005, Plymouth Meeting, Pa. Available online at: (Accessed March 11, 2010)
2 Occupational Safety and Health Administration: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. Available online at: (accessed March 10, 2010)
3 International Association for Healthcare Security and Safety: Healthcare Security: Basic Industry Guidelines, October 2009
4 American Society of Health-System Pharmacists: Policy Position on Education, Prevention, and Enforcement Concerning Workplace Violence (0810). Available online at: (Accessed March 10, 2010)

Patient Safety Advisory Group

The Patient Safety Advisory Group informs The Joint Commission on patient safety issues and, with other sources, advises on topics and content for Sentinel Event Alert. Members: James P. Bagian, M.D., P.E. (chair); Michael Cohen, R.Ph., M.S., Sc.D. (vice chair); Jane H. Barnsteiner, R.N., Ph.D., FAAN; Jim B. Battles, Ph.D.; William H. Beeson, M.D.; Patrick J. Brennan, M.D.; Martin H. Diamond, FACHE; Cindy Dougherty, R.N., CPHQ; Frank Federico, B.S., R.Ph.; Steven S. Fountain, M.D.; Suzanne Graham, R.N., Ph.D.; Jerril W. Green, M.D.; Ezra E.H. Griffith, M.D.; Peter Gross, M.D.; Carol Haraden, Ph.D.; Martin J. Hatlie, Esq.; Jennifer Jackson, B.S.N., J.D.; Henri R. Manasse, Jr., Ph.D., Sc.D.; Jane McCaffrey, MHSA, DFASHRM; David Mechtenberg; Mark W. Milner, R.N., MBA, MHS; Jeanine Arden Ornt, J.D.; Grena Porto, R.N., M.S., ARM, CPHRM; Matthew Scanlon, M.D.; Carl A. Sirio, M.D.; Ronni P. Solomon, J.D.; Dana Swenson, P.E., MBA; Susan M. West, R.N.

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