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Stand up AFFIRM: Enough already! Ending Workplace Violence: Emergency Medicine News

EP safety, workplace violence, emergency 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 deserves the same robust response that hospitals apply to other negative health outcomes, such as patient falls and associated infections. to catheters.

Every assault, whether physical or verbal, points to a need to reduce risk, improve quality and reduce variation in practice between health systems and care settings. 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 reduce workplace violence. (Sentinel Event Alert. April 17, 2018; These new requirements come into effect on January 1, and emergency physicians can take steps now to help their hospitals comply.

  • Recognizing and Discussing Workplace Violence in Your Emergency Department. Verbal aggression is a risk factor for assault and battery (AAOHN J. 2006;54[9];397), and passive tolerance of aggression, including verbal aggression, creates an environment conducive to more serious crimes.
  • Ensure immediate support for victims and witnesses after each act of violence. This includes the treatment of acute injuries and the alleviation of post-traumatic sequelae. If time off is needed, have clear and supportive procedures to avoid planning hardship and clarify how time off will be compensated.
  • Help the victim report the event internally and pursue legal avenues in a timely manner. When a patient harms staff, the patient can be charged with a number of crimes, ranging from assault and battery to disorderly conduct, trespassing, criminal threats, breach of a protective order, harassment , harassment and illegal possession of weapons, among others. Assaulting emergency medical professionals is a felony in most states. It is helpful to provide training on the reporting process in your jurisdiction and guidance on completing a HIPAA-compliant testimonial. The indicated timeline indicates the order of operations for reporting and prosecuting workplace violence. Individual court systems may have different timelines, but the processes are similar across jurisdictions.
  • Prevent future damage from the same author. The patient may be served with a no trespassing order for hospital grounds that applies upon discharge from the emergency department. Also consider seeking a restraining order if the crime meets your state’s criteria. When implemented appropriately, these restrictions do not prevent the patient from accessing necessary emergency medical care or violate the EMTALA. Information entered into police databases also allows officers to track offenders and understand who they are assaulting, which can help prevent future cases by the same assailant.
  • Conduct root cause analyzes of all acts of violence against staff. This and related quality improvement benchmarking are common practices for addressing patient harm and adverse outcomes due to errors in medical and nursing practice. The same methods and rigor must be applied to address staff harm and adverse outcomes caused by patient conduct. From each event, we can identify risk factors, trigger events, and other staffing, system response, and physical facility variables that should be optimized to prevent or mitigate future acts of violence.
  • Drive with data. Information on workplace violence exists in various databases and can be improved by making it easier for staff to report violent events. Currently, acts of workplace violence are vastly underreported by emergency service providers. (Permanent J. 2015;19[2]:e113; Collect, track and publish regular reports on workplace violence and share this information with hospital staff, patients and the communities we serve. Data communication plays a vital role in changing social norms.
  • Anticipating and staying ahead of violence. Many of the risk factors for violent behavior manifest themselves in the actions of patients long before they seek emergency care. A history of violence is among the strongest risk factors for future violent behavior, and altered mental status associated with decompensated mental illness, dementia, delirium, and substance intoxication is commonly presented by perpetrators of workplace violence.

Order of Operations for Reporting and Prosecuting Workplace Violence

People who are aware of these risk factors, like those who refer these patients for emergency care, share the responsibility of informing health care providers of the risk of violence. When a history 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 dealing with patients at risk of workplace violence.

When a provider-patient relationship becomes a victim-offender relationship, it negatively impacts our ability to provide compassionate care and undermines the culture of safety in health care. Affirmative actions such as reporting, laying charges, and barring non-medical contact provide legal barriers and protections for us and our staff, and are necessary elements in implementing a policy of tolerance. zero in workplace violence. Ultimately, ending ER workplace violence requires changing social norms, and each of us has a role to play now to ensure a safer work environment in the future.

Dr. Barsottiis the founding CEO 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 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 Response and Violence Prevention. Read his past columns on, find more information about AFFIRM at, and follow the foundation on Twitter@ResearchAffirm.