Lab Coats With Bullseyes on Them? Protecting Yourself Against Violence

Gregory A. Hood, MD

Disclosures

July 29, 2016

In This Article

How We Can Defend Ourselves

As with politics, all violence is fundamentally local. There are steps by which the potential for violence against healthcare workers can be avoided, deterred, de-escalated, and defended against. To place those points in a wider framework, physicians should:

1. Acknowledge up front that the potential for violence exists. The US Department of Justice explicitly acknowledges this, having established in 1998 the National Task Force on Violence Against Health Care Providers.[6] Healthcare workers must also insist that the perpetration of violence will not be tolerated. As controlled substance agreements with patients have become more standard, even required, specific contractual language has emerged to address the potential of violence by patients. For example, I've reviewed the proprietary agreements from several facilities that have specifically included verbiage stating that inappropriate physical or verbal conduct by patients will not be tolerated and will be grounds for permanent dismissal from the medical setting.

2. Support local action. To serve as a more meaningful deterrent, states as different as Idaho and New York, among others, have considered or enacted bills and laws that elevate the severity of an assault charge against a healthcare worker to an automatic felony.

3. Make use of reminder systems. Whether using paper charts or electronic health records, physicians should make appropriate and timely use of flag systems that can alert healthcare workers to a risk for, or a past pattern of, violent behavior from specific patients. Unfortunately, as the experience at Veterans Affairs medical facilities has shown, the lack of timely adherence to such protocols—those assigning warning record flags, for example—remains a cause for substantial concern.[7]

4. Design facilities and protocols with security and safety inmind. As reflected in long-standing policies by the American College of Emergency Physicians,[8] facilities have been encouraged to incorporate, in addition to security personnel and surveillance equipment, such deterrents as physical barriers into the design flow of the practice. A balance can and has to be struck, however, between security and complexity of access for healthcare workers and patients alike. Similarly, your practice's protocols also need to take the different threats into account.

The Occupational Safety and Health Administration has recently updated an extensive publication, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.[9] This includes detailed reviews of safety measures, including alarm systems, proper use of exits and safe rooms, furniture arrangements, and appropriate barriers and protections, among other considerations.

Historically, hospital protocols have instructed staff to respond to the location where a patient is being violent. For safety reasons, this has been coded differently by different hospitals. "Code white" is one common designation. Recognizing that the threats may now include an armed patient, a growing number of facilities have incorporated a "code silver" to designate an "active shooter" circumstance. These color-coded alerts are important because of the danger of medical staff converging en masse on an armed perpetrator.

5. Understand that violence is the problem, and plan accordingly. Too often the horror of the attack is redirected into attention on the instrument of the attack. It should be obvious to the empathetic among us that the suffering of the victims and their families is diminished by such trite diversions. It didn't matter, for instance, that Dr MarDock's assailant was "unarmed"; the outcome of the assault was tragically the same. At such moments, the focus should rightly be on the nature of the victim's experience and potential steps to preempt the next such encounter.

Having been personally assaulted by bare hands and threatened (but not drawn on) by concealed weapons, I can attest to two things: First, the threat of bodily harm, for all intents and purposes, carries the same gravity in each situation. The weapon of choice can be fists, a knife, a bat, a bomb, a firearm, or even a vehicle or its contents. Each and any of these things can take a life.

Second, signs that expressly prohibit weapons, such as those commonly seen on the sliding doors of medical institutions, do nothing to deter someone who is intent upon doing harm. They didn't stop either patient who threatened me from carrying their pistols into the facility. Indeed, there's debate that such signs may highlight places for those who harbor ill intent to target.

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