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Course 776 - Preventing Workplace Violence in Healthcare

Safety guides and audits to make your job as a safety professional easier

Hazard Prevention and Control

alarm systems
A panic button, such as this one, is an example of an engineering control.

After the systematic worksite analysis is complete, the employer should employ control strategies to prevent or control the hazards that were identified. To do this, the employer should:

  1. identify and evaluate control options for workplace hazards;
  2. select effective and feasible control strategies control the hazards;
  3. implement these controls in the workplace;
  4. follow up to confirm that these controls are being used and maintained properly; and
  5. evaluate the effectiveness of controls and improve, expand, or update them as needed.

Hazard control strategies are generally categorized, in order of effectiveness, as:

  1. elimination/substitution;
  2. engineering controls; and
  3. administrative/work practice controls.

These strategies can also be applied to the field of workplace violence. In addition, employers should ensure that, if an incident of workplace violence occurs, post-incident procedures and services are in place and/or immediately made available.


The best way to eliminate a hazard is to eliminate it or substitute a safer work practice. While these substitutions may be difficult in the therapeutic healthcare environment, an example may be transferring a client or patient to a more appropriate facility if the client has a history of violent behavior that may not be appropriate in a less secure therapeutic environment.

Engineering Controls

Engineering controls are physical changes that either remove the hazard from the workplace or create a barrier between the worker and the hazard. In facilities where it is appropriate, there are several engineering control measures that can effectively prevent or control workplace hazards. The measures taken should be site-specific and based on the hazards identified in the worksite analysis appropriate to the specific therapeutic setting. For example, closed circuit videos and bulletproof glass may be appropriate in a hospital or other institutional setting, but not in a community care facility.

Here are some engineering control options employers may choose to protect their employees:

  • Install and regularly maintain alarm systems and other security devices, panic buttons, hand-held alarms or noise devices, cellular phones and private channel radios where risk is apparent or may be anticipated. Arrange for a reliable response system when an alarm is triggered.
  • Use a closed-circuit video recording for high-risk areas on a 24-hour basis. Public safety is a greater concern than privacy in these situations.
  • Place curved mirrors at hallway intersections or concealed areas.
  • Enclose nurses' stations and install deep service counters or bullet-resistant, shatter-proof glass in reception, triage and admitting areas or client service rooms.
  • Provide employee "safe rooms" for use during emergencies.
  • Lock doors to staff counseling rooms and treatment rooms to limit access.
  • Arrange furniture to prevent entrapment of staff.
  • Provide lockable and secure bathrooms for staff members separate from patient/client and visitor facilities.
  • Lock all unused doors to limit access, in accordance with local fire codes.

Note: Services performed in the field (e.g., home health or social services) often occur in private residences where some engineering controls may not be possible or appropriate.

For more examples of engineering controls see the OSHA guidelines

Administrative Controls

alarm systems

Administrative controls are always necessary in an effective violence prevention program. They are established in conjunction with engineering and work practice controls and are especially important when engineering controls are not feasible or not completely protective. These controls use formal program policies, processes, and procedures to aid supervisors, managers, and employees in making decisions and taking action.

Some examples of administrative controls include the following:

  • Supervisors and managers will display a commitment to preventing workplace violence and provide adequate support during emergencies.
  • All managers, supervisors, and employees will follow written violence prevention program policies and procedures.
  • All managers, supervisor, and employees will receive initial and recurring violence prevention program training. Instruction will emphasize program requirements, early warning signs, and safe work practice. Hands-on training will focus on how to report incidents and de-escalation and defensive techniques in response to incidents.
  • Scheduled awareness drills will be conducted in each department.
  • Employees will report all incidents of workplace violence or threats of violence to a supervisor or manager.
  • Reports to supervisors or managers will be held strictly confidential.
  • Confidential documentation of incidents of violence will be maintained to help determine necessary actions to prevent recurrences.
  • Written procedures will be followed for requesting police assistance or filing charges when assaulted.
  • Institute a sign-in procedure with passes for visitors. Enforce visitor hours and procedures.
  • Supervisors and managers will respond promptly to all complaints.
  • A trained response team will be created to respond to emergencies.
  • Only properly trained security officers are authorized to deal with aggressive behavior.
  • Ensure that adequate and properly trained staff are available to restrain patients, if necessary.

Work Practice Controls


Work practice controls are closely associated with administrative controls. Whereas administrative controls focus on common policies and procedures that apply to all supervisors, managers, and employees, work practice controls focus on unique individual precautions each employee can take to stay safe while performing their jobs.

Examples of work practice controls include:

Be on the alert for:

  • verbally expressed anger and frustration
  • body language such as threatening gestures
  • signs of drug or alcohol use
  • presence of a weapon

Use effective de-escalation techniques:

  • Present a calm, caring attitude.
  • Don't match the threats.
  • Don't give orders.
  • Acknowledge and validate the person's feelings.
  • Avoid any behavior that may be interpreted as aggressive.

Work Practice Controls (Continued)

Do not work alone:

  • in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable.
  • in poorly-illuminated or secluded rooms.
  • when performing intimate physical examinations of patients.
  • Ask for a security escort when walking to parking areas in the evening or late hours.
  • Always use the "buddy system," especially when you believe personal safety may be threatened.

Be aware:

  • Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor.
  • Be vigilant throughout the encounter.
  • Always keep an open path for exiting - don't let the potentially violent person stand between you and the door.

Take these steps if you can't defuse the situation quickly:

  • Remove yourself from the situation.
  • Call security for help.
  • Report any violent incidents to your management.

For more examples of administrative and work practice controls see the OSHA guidelines

Employer Responses to Incidents of Violence


Post-incident response and evaluation are essential to maintaining an effective violence prevention program. When an incident occurs, the immediate first steps are to provide first aid and emergency care for the injured workers and to take any measures necessary to prevent others from being injured.

All workplace violence programs should provide comprehensive treatment for employees who are victimized personally or may be traumatized by witnessing a workplace violence incident. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of its severity. Also, injured workers should be provided transportation to medical care if not available on site.

Victims of workplace violence could suffer a variety of consequences in addition to their actual physical injuries. These may include:

  • short- and long-term psychological trauma
  • fear of returning to work
  • changes in relationships with coworkers and family
  • feelings of incompetence, guilt, powerlessness
  • fear of criticism by supervisors or managers

A strong follow-up program for these workers will not only help them address these problems but also help prepare them to confront or prevent future incidents of violence.

Post-Incident Follow-up and Counseling

Several types of assistance can be incorporated into the post-incident response. For example, trauma-crisis counseling, critical-incident stress debriefing or employee assistance programs may be provided to assist victims.

Certified employee assistance professionals, psychologists, psychiatrists, clinical nurse specialists or social workers may provide this counseling or the employer may refer staff victims to an outside specialist. The employer may establish an employee counseling service, peer counseling or support groups. Counselors should be well trained and have a good understanding of the issues and consequences of assaults and other aggressive, violent behavior.

Appropriate and promptly rendered post-incident debriefings and counseling reduce acute psychological trauma and general stress levels among victims and witnesses. This type of counseling educates staff about workplace violence and positively influences workplace and organizational cultural norms to reduce trauma associated with future incidents.

Investigation of Incidents

Once the immediate needs following an incident are taken care of, an incident investigation should begin promptly. The basic steps in conducting incident investigations are:

  1. Report as required. Determine who needs to be notified, both within the organization and outside (e.g., authorities), when there is an incident. Understand what types of incidents must be reported, and what information needs to be included. If the incident involves hazardous materials additional reporting requirements may apply.
  2. Involve workers in the incident investigation. The employees who work most closely in the area where the event occurred may have special insight into the causes and solutions.
  3. Identify Root Causes: Identify the root causes of the incident. Don't stop an investigation at "worker error" or "unpredictable event." Ask "why" events occurred at least five times. Doing this will help you arrive as the safety management system weaknesses (programs, policies, processes, procedures) that may have contributed to the incident.
  4. Collect and review other information. Depending on the nature of the incident, records related to training, maintenance, inspections, audits, and past incident reports may be relevant to review.
  5. Investigate Near Misses. A near miss situation that could potentially have resulted in death, injury, or illness should be promptly investigated as well. Near misses are caused by the same conditions that produce more serious outcomes, and signal that some hazards are not being adequately controlled, or that previously unidentified hazards exist.

For more information on Incident/Accident Investigation principles and procedures, see OSHAcademy Course 702.

Case Reports

  • A security screening system in a Detroit hospital included stationary metal detectors supplemented by hand-held units. The system prevented the entry of 33 handguns, 1,324 knives, and 97 mace-type sprays during a 6-month period.
  • A violence reporting program in the Portland, Oregon, VA Medical Center identified patients with a history of violence in a computerized database. The program helped reduce the number of all violent attacks by almost 92% by alerting staff to take additional safety measures when serving these patients.
  • A system restricting movement of visitors in a New York City hospital used identification badges and color-coded passes to limit each visitor to a specific floor. The hospital also enforced the limit of two visitors at a time per patient. In 18 months, these actions reduced the number of reported violent crimes by 65%.




Before beginning this quiz, we highly recommend you review the module material. This quiz is designed to allow you to self-check your comprehension of the module content, but only focuses on key concepts and ideas.

Read each question carefully. Select the best answer, even if more than one answer seems possible. When done, click on the "Get Quiz Answers" button. If you do not answer all the questions, you will receive an error message.

Good luck!

1. If violence occurs, _____ response can be an important tool in preventing future incidents.

2. Providing employee “safe rooms” for use during emergencies is an example of a(n) _____.

3. Which of the following could be signals that may be associated with impending violence?

4. If you cannot defuse a violent situation, you should _____.

5. Changes in work practices can help prevent violent incidents.

Have a great day!

Important! You will receive an "error" message unless all questions are answered.