As a medical student during a surgical rotation in the 90s at the old Boston City Hospital, I started locking the resident’s call room door whenever I was attempting to catch a cat nap.  This came on the heels of the morning after the chief surgical resident was jumped and beaten while he was sleeping in the call room, by a completely random person wandering the floors of the hospital.  Over the years I have seen patients attack patients, nurses, caseworkers and physicians.  All completely random acts without provocation in the middle of emergency departments, hospital wards and out of the way sundry areas like stairwells or the hospital garage.  The incidence and severity of violence is on the rise in healthcare settings.  Dr. Michael Davidson, the 44-year-old Boston based cardiovascular surgeon who was murdered just weeks ago by a patient’s relative, is one recent tragedy.  On July 24, 2014, a psychiatric outpatient in Pennsylvania shot and killed a caseworker and wounded a psychiatrist.  In just over a year, in New Hampshire, there have been nurses and staff who have been severely beaten by patients and a patient shot to death by a family member. These occurrences, individually, should not be minimized as outliers or as true true and unrelated; that likely won’t occur but once in a millennium.

“The Joint Commission, a national accrediting agency, soberly noted last year that health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide. Violence is most common in psychiatric facilities and emergency departments, but can also be seen in waiting rooms, long-term care centers and critical care units.  According to a 2010 survey from the Emergency Nurses Association, more than half of ER nurses were victims of physical violence and verbal abuse, including being spit on, shoved, or kicked; one in four reported being assaulted more than 20 times over the past three years. The survey noted that the violence seemed to be increasing at the same time the number of alcohol-, drug- and psychiatric-related patients was rising.”  Understanding patient violence against health care workers, an op-ed published on February 2, 2011, in USA Today.  

Knee-jerk reactions arise quickly following sentinel events.  Just as violence has permeated the campuses and walls of universities and community schools, reactionary fervor comes from people being scared to death.  It is a nanosecond for demands to be made for metal detectors and locked down points of entry and egress.  However, even if that were possible, many realize these are more extensive and comprehensive solutions that must be implemented methodically and tailored to the dynamic state of respective hospitals, healthcare centers or academic facilities.  “It is impossible to eliminate workplace violence in healthcare settings; however, there are ways to reduce the potential for violent occurrences and minimize the impact of any violent situation that may arise.”  Refer to ECRI, Healthcare Risk, Quality & Safety Guidance, Violence in Healthcare Facilities executive Summary, 03.01.2011.  Bringing together national programs with state initiatives is essential, but these are not distinctly detailed enough to offer preventive models for healthcare facilities, where they are designed to be executed after the fact.

Active shooter awareness with comprehensive curricula provided by the Department of Homeland Security (DHS) is a broadly designed resource that can be of great benefit to a community. “DHS aims to enhance preparedness through a ”whole community” approach by providing training, products, and resources to a broad range of stakeholders on issues such as active shooter awareness, incident response, and workplace violence. In many cases, there is no pattern or method to the selection of victims by an active shooter, and these situations are by their very nature are unpredictable and evolve quickly.”  Refer to DHS official website.  Rather than quick solutions to create citadel-like safety measures, investing in the necessary staffing and psychiatric support in partnership with security processes and policies can be well-designed for early recognition and prevention of high risk situations.   The Joint Commission lists some of the most essential areas of exposure.  Refer to The Joint Commission for position papers and references. A few that can be very challenging to correct and particularly so to maintain are noted below:

  • 62 percent of events were in need of policy and procedure development and implementation.
  • Human resources-related factors for staff education and competencies.
  • 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.

The eye opener that follows these isolated horrific events sparks rapid responses of many to batten down the hatches, set recommendations to wand every visitor on the campus, and evaluate policies/procedures that allow all others the right to carry a concealed firearm.  Rather, following the direction of what The Joint Commission and others see in having more depth in human resources and psychiatric services with integrated education and communication strategies, will better serve healthcare to decrease the growing risk of extreme acts of violence from occurring amongst our patients and colleagues.


Lukas Kolm, MD, MPH

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