Medical Workplace Violence Prevention Guidelines

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Earliest Guidelines in California Program

By Eugene Schmuckler; PhD MBA MEd CTS

By Dr. David E. Marcinko MBA


At least 5 people are dead and multiple people are injured following a shooting at the Natalie Building at St. Francis Hospital in Tulsa, Oklahoma.



The impact of medical workplace violence became widely exposed on November 6, 2009 when 39 year old Army psychiatrist Maj. Nidal M. Hasan MD, a 1997 graduate of Virginia Tech University who received a medical doctorate in psychiatry from the Uniformed Services University of the Health Sciences in Bethesda, Maryland, and served as an intern, resident and fellow at the Walter Reed Army Medical Center in the District of Columbia, went on a savage 100 round shooting spree and rampage that killed 13 people and injured 32 others. In April 2010 he was transferred to Bell County Jail in Belton, Texas awaiting trial.

Federal Government Guidelines

The federal government and some states have developed guidelines to assist employers with workplace violence prevention. For instance, one of the earliest sets of guidelines for a comprehensive workplace violence prevention program was published in 1993 by California OSHA. This resulted from the murder of a state employee. In 1996, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers was published by OSHA.

Book Link:

OSHA Guidelines

In its guidelines, OSHA sets forth the following essential elements for developing a violence prevention program:

  • Management commitment — as seen by high-level management involvement and support for a written workplace violence prevention policy and its implementation.
  • Meaningful employee involvement — in policy development, joint management-worker violence prevention committees, post-assault counseling and debriefing, and follow-up are all critical program components.
  • Worksite analysis — includes regular walk-through surveys of all patient care areas and the collection and review of all reports of worker assault. A successful job hazard analysis must include strategies and policies for encouraging the reporting of all incidents of workplace violence, including verbal threats that do not result in physical injury.
  • Hazard prevention and control — includes the installation and maintenance of alarm systems in high-risk areas. It may also include the training and posting of security personnel in emergency departments. Adequate staffing is an essential hazard prevention measure, as is adequate lighting and control of access to staff offices and secluded work areas.
  • Pre-placement and periodic training and education — must include educationally appropriate information regarding the risk factors for violence in the healthcare environment and control measures available to prevent violent incidents. Training should include skills in aggressive behavior identification and management, especially for staff working in the mental health and emergency departments.

On May 17, 1999, Governor Gary Locke signed the New Workplace Violence Prevention Act for the state of Washington. This act mandates that each healthcare setting in the state implement a plan to reasonably prevent and protect employees from violence.

New Washington Workplace Violence Prevention Act

According to this act, prevention plans need to address security considerations related to:

  • physical attributes of the healthcare setting;
  • staffing, including security staffing;
  • personnel policies;
  • first aid and emergency procedures;
  • reporting of violent acts; and
  • employee education and training.

Prior to the development of an actual plan, a security and safety assessment needs to be conducted to identify existing or potential hazards. The training component of the plan must include the following topics:

  • general safety procedures;
  • personal safety procedures;
  • the violence escalation cycle;
  • violence-predicting factors;
  • means of obtaining a patient history form from a patient with violent behavior;
  • strategies to avoid physical harm;
  • restraining techniques;
  • appropriate use of medications as chemical restraints;
  • documenting and reporting incidents;
  • the process whereby employees affected by a violent act may debrief;
  •  any resources available to employee for coping with violence; and
  • the healthcare setting’s workplace violence prevention plan.


The act further mandates that any hospital operated and maintained by the State of Washington for the care of the mentally ill is required to provide violence prevention training to affected employees identified in the plan on a regular basis and prior.

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18 Responses

  1. Medical Workplace Violence

    More info from Uncle Sam.

    Hope Rachel Hetico RN MHA
    [Managing Editor]


  2. Receptionists take on the brunt of patients’ emotions

    Although we often focus on how clinicians, particularly physicians, can provide more empathetic, compassionate care, there’s been little credit given to front-line administrative staff for the skill in managing patients’ emotions as part of carrying out their other duties.

    But, a new study out of the United Kingdom takes a deeper look at the role of the medical office receptionist and offers advice on how practices can set up front-desk staffers for smoother interactions with patients.

    Ann Miller RN MHA


  3. Emergency Room Nurses Face Violence

    Swearing, spitting, choking – ER nurses endure this and more

    I am a male ER nurse, and this topic, post and comments are timely, indeed. Thank you Dr. Schmuckler and the ME-P.



  4. Dr. Schmuckler,

    In the November 2011 issue of Hospitals and Health Networks [H&HN] there was an article on medical workplace violence. But, I enjoyed your essay much more.

    That’s the way to stay ahead of the curve.



  5. Two shot at Connecticut hospital

    As just reported by NBC News and staff, two people were shot at a long-term-care hospital in New Britain, Conn., and a suspect was in custody.

    The extent of the injuries wasn’t known, but the suspect was a worker at the Hospital for Special Care, a long-term acute-care hospital specializing in pulmonary and brain injuries and other complex conditions.

    So sad.



  6. How to reign in docs gone wild

    A physician who threatened to use an AK-47, a sexually harassing doctor who looked at porn on work computers and a specialist who used to cause nurses to draw straws with the loser having to interact with her.

    These were some of the horror stories about disruptive provider behavior that Dean White, a Texas-based consultant and former chief of the medical staff at Texas Health Harris Methodist HEB Hospital in Dallas, shared at this week’s American College of Healthcare Executives’ (ACHE) annual congress in Chicago; according to journalist Karen M. Cheung.



  7. Medical Workplace Violence

    A large number of medical workplace violence by patients occurs in Emergency Rooms by mentally ill patients. Many US citizens don’t have a family doctor or social safety net and end up in the ER. Many states have decided to treat the symptom such as Massachusetts that have enacted a law that makes an assault on an emergency medical technician a separate crime with its own set of penalties. California has also enacted laws thanks to the RN association there.

    Healthcare workers need to be protected. But due to the “Great Recession” with massive layoffs more patients are losing health insurance coverage and mental healthcare and are very agitated when they enter a hospital ER.

    The real question : What can we do to provide mental health care to the large number of individuals lacking coverage in this country?


    Randle, Emily. “Not In A Day’s Work.” National Nurse 106.9 (2010): 12. MasterFILE Premier. Web. 3 May 2012.


    David K. Luke MIM
    [Financial Advisor]
    Certified Medical Planner™ candidate


  8. Nidal Malik Hasan MD

    Ft. Hood gunman – guilty on all counts – but has justice been served?
    Please comment.



  9. Shooting at Reno medical center leaves two dead, two wounded

    A gunman opened fire inside a Nevada medical office today, killing one person and wounded two others before killing himself.



  10. Hospitals

    Hospitals are a special type of facility where life and death situations play out within the complex 24/7.

    It is just as important to design the facility to provide maximum protection of the staff, as it is for families of patients where appropriate; Emergency, Maternity, ED, OR, etc.

    Ken Yeung MBA CMP™ candidate


  11. Doctor fired back at gunman in PA hospital attack

    An exchange of gunfire occurred on the third floor of the Wellness Center at Mercy Fitzgerald Hospital, a 204-bed community teaching hospital just southwest of Philadelphia.

    Ann Miller RN MHA


  12. Gunman kills 2 at Parrish Medical Center

    A man entered a patient’s room at Parrish Medical Center in Titusville, Fla., early Sunday and opened fire, killing an elderly female patient and a hospital employee in what appears to be a random attack, authorities just told CNN.

    Hope Hetico RN MHA


  13. Multiple People Shot at Bronx Lebanon Hospital

    Multiple people were shot at New York’s Bronx Lebanon Hospital on Friday, June 30, 2017.

    How sad; a physician.

    Dr. David Marcinko MBA


  14. Half of Hospital Security Directors Report Increased Physical Violence

    Tarsus Direct recently released an analysis on security at healthcare facilities. Here are some key findings from the report:

    • 47% of security directors reported an increase in physical violence over last year.
    • 1 in 5 security directors cited an increase in external hacking attacks.
    • Almost a quarter say their facilities are unprepared for shooting incidents.
    • 7% of hospitals reported using walk-through metal detection equipment in the ED.

    Source: Healthcare Finance News, August 21, 2018


  15. 2021 UoP Violence

    Hospital patient stabs Pennsylvania doctor in head and face ‘multiple times’ during treatment

    Dr. David E. Marcinko MBA


  16. Two Men Murdered U.S. Army Physician Couple on Victims’ Front Lawn
    Dr. David Edward Marcinko MBA


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