Standing AFFIRM: Enough Already! Ending Workplace Violence : Emergency Medicine News


EP safety, workplace violence, ED management
EP safety, workplace violence, ED management:

Chris Coyne, MD, who consented to the publication of this photo, was assaulted by a patient.


Every act of violence against an emergency health care provider is a sentinel event, and it merits the same robust response that hospitals apply to other negative health outcomes, such as patient falls and catheter-associated infections.

Each assault, whether physical or verbal, indicates a need to reduce risk, improve quality, and reduce variation in practice across health systems and care environments. The Joint Commission recently created standards to provide a framework to guide hospitals in defining workplace violence; developing strong workplace violence prevention systems; and developing a leadership structure, policies, and procedures, reporting systems, post-incident strategies, training, and education to decrease workplace violence. (Sentinel Event Alert. Apr. 17, 2018; These new requirements become effective Jan. 1, and emergency physicians can take steps now to help their hospitals comply.

  • Acknowledge and discuss workplace violence in your emergency department. Verbal assaults are a risk factor for battery (AAOHN J. 2006;54[9];397), and passive tolerance of assaults, including verbal ones, creates an environment conducive to more serious crimes.
  • Ensure immediate care for victims and witnesses after each act of violence. This includes treating acute injuries and mitigating posttraumatic sequelae. If time off from work is needed, have clear and supportive procedures to avoid scheduling hardships and clarify how this time off will be compensated.
  • Assist the victim with reporting the event internally and pursuing legal channels in a timely fashion. When a patient harms staff, the patient may be charged with a number of crimes, ranging from assault and battery to disorderly conduct, trespassing, criminal threatening, violation of a protection order, stalking, harassment, and unlawful possession of weapons, among others. Assaulting emergency health care professionals is a felony in most states. Providing education on the reporting process in your jurisdiction and guidance for completing HIPAA-compliant testimony is helpful. The timeline shown indicates the order of operations for reporting and prosecuting workplace violence. Individual court systems may have different timelines, but the processes are similar among jurisdictions.
  • Prevent future harm from the same perpetrator. The patient may be served a no-trespass order for the hospital grounds that apply upon release from the ED. Also consider petitioning for a restraining order if the crime meets your state’s criteria. When implemented appropriately, such restrictions do not prevent patient access to necessary emergency medical care or violate EMTALA. Information entered into police databases also enables police officers to track offenders and understand who they victimize, which may help prevent future cases by the same perpetrator.
  • Conduct root cause analyses on all acts of violence against staff. This and related quality improvement benchmarking are common practices to address patient harms and undesired outcomes due to errors in medical and nursing practice. Identical methods and rigor must be applied to address staff harms and undesired outcomes caused by the conduct of patients. From each event, we can identify risk factors, precipitating events, and other variables related to staffing, system response, and physical plant that should be optimized to prevent or mitigate future acts of violence.
  • Drive with data. Information about workplace violence exists in diverse databases and may be improved by facilitating staff reporting of violent events. Presently, acts of workplace violence are grossly underreported by ED providers. (Perm J. 2015;19[2]:e113; Gather, trend, and publish regular reports on workplace violence and share this information with hospital staff, patients, and the communities we serve. Communicating data plays an essential role in changing social norms.
  • Anticipate and stay upstream of violence. Many of the risk factors for violent conduct are manifest in patients’ actions long before they seek care in the ED. A history of violence is among the strongest risk factors for future violent conduct, and altered mental status associated with decompensated mental illness, dementia, delirium, and substance intoxication is commonly exhibited by perpetrators of workplace violence.

Order of Operations for Reporting and Prosecuting Workplace Violence

Individuals who are aware of these risk factors, such as those who refer such patients for emergency care, share responsibility for advising health care providers of the risk for violence. When histories or risk factors for violence are identified, the information should be included in the medical record to ensure appropriate care and precautions by all providers. Consider developing safety checklists for treating patients at risk of perpetrating workplace violence.

When a provider-patient relationship becomes one of victim-offender, it negatively influences our ability to provide compassionate care and undermines the health care culture of safety. Positive actions such as reporting, pressing charges, and banning nonmedical contact provide a legal barrier and protections for us and our staff, and they are necessary components in the implementation of a zero-tolerance policy of workplace violence. Ultimately, ending workplace violence in the ED requires changing social norms, and each one of us has a role to play right now in securing a safer work environment in the future.

Dr. Barsottiis the founding chief executive officer of the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) and an emergency physician at Berkshire Medical Center in Pittsfield, MA. He is also a past chair of the trauma and injury prevention section of the American College of Emergency Physicians, and a member of the Massachusetts Medical Society committees on preparedness and violence intervention and prevention. Read his past columns at, find more information about AFFIRM at, and follow the foundation on Twitter@ResearchAffirm.


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