Case-Controlled Analysis of Patient-Based Risk Factors for Assault in the Healthcare Workplace

Ilene A. Claudius, MD; Shoma Desai, MD; Ebony Davis, MS; Sean Henderson, MD


Western J Emerg Med. 2017;18(6):1153-1158. 

In This Article

Abstract and Introduction


Introduction: Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting.

Methods: We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant's (patient's) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center.

Results: We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different.

Conclusion: Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.


Violence directed at healthcare workers (HCW) is not uncommon. In the U.S., 13% of healthcare employees have reported at least one assault,[1] and 1.9 physical assaults resulting in an injury occur for every 100,000 worker hours.[2] The incidence of HCW assault in the U.S. is 1.65[3] or a median of 11 physical attacks per year per site.[4] Physical assaults comprise 6–21%[5] of all threatening behavior to which HCW are exposed, with verbal assaults, threats, and property damage accounting for the balance.[6,7] Clearly, this is not evenly distributed throughout hospitals and provider type. Psychiatric, rehabilitation, and geriatric areas have all been shown to have a higher number of assaults.[8,9] As the emergency department (ED) is the front line for these patients, often in their most decompensated state, the threat of aggression toward HCW is a significant concern for ED providers.[10] In a survey study, 78% of emergency medicine residents or attending physicians reported being the victim of at least one act of workplace violence.[5]

Many reports of risk factors in the healthcare workplace have focused on the HCW themselves. Females, individuals older than 50 years of age, and staff members with longer tenure reported higher numbers of assaults and of fear.[4,11] Patient-staff conflicts substantially correlated and intra-staff conflict moderately related to frequency of assault.[12] The psychiatric literature has identified a history of violent episodes,[13,14] psychosis,[14] drug misuse,[14] paranoid schizophrenia,[15] and anti-social personality disorder[16,17] as predictors of violence. However, these associations are primarily studied in inpatient psychiatric facilities or general criminal behavior. Predictors in the emergency and acute healthcare setting are lacking. One patient-oriented cause that has been identified is dissatisfaction with care.[18] Unfortunately, often this is not shared with the healthcare team until the violence has occurred. Others have been suggested by interviews of ED personnel, including psychiatric patients, anxiety, staring, mumbling, pacing, and gang violence.[19,20,21,22] The goal of this study was to use data from reported HCW assaults to begin to identify more clearly patient-level risk factors associated with assaultive behavior in the ED or following admission through the ED.