Risk Managmentby Holly Taylor, RN-BC, BSN, JD
Ms. Taylor is Risk Manager at PRMS, Inc., Arlington, VA.

I have heard about physicians and nurses being subjected to violence by patients in the workplace. Is this really a problem and, if so, is there anything that can or should be done to reduce the risk?

Innov Clin Neurosci. 2013;10(3):40–42

This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and onsite risk management audits, and other resources to healthcare providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers may provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so “clinician” is used to indicate all treatment team members.


I have heard about physicians and nurses being subjected to violence by patients in the workplace. Is this really a problem and, if so, is there anything that can or should be done to reduce the risk?


The risk. Patient violence directed toward clinicians is an ever-present risk that requires attention and preparation to decrease the risk and provide for the safety of the clinician. Tragic incidents of violence against clinicians have been reported in the news:

  • A National Institute of Mental Health administrator and expert in the diagnosis and treatment of schizophrenia was beaten to death in his office by a patient. Five years later, this patient was charged with murdering his roommate at a state hospital for the mentally ill.[1]
  • A psychiatrist in Virginia was killed in his home office by a patient.[2]
  • A physician at Johns Hopkins Hospital was shot by a man who was distraught about his mother’s care. The man then killed his mother and himself.[3]

Sadly, these reported incidents are only a glimpse of the overall problem. Although commentators opine that the frequency of violence against clinicians is increasing, the true incidence is hard to know. This is due, in part, to information collected from a variety of sources using different methodologies for gathering data, lack of reporting protocols and mechanisms, and failure to report nonphysical violent incidents, such as verbal abuse, threats, and stalking.[4]

However, data from a number of sources provide a measure of the extent of the problem and the impact on clinicians. Bureau of Labor Statistics data from 2000 show that “48 percent of all non-fatal occupational assaults and violent acts occurred in health care and social services” settings.[5] A Department of Justice survey for 1993 to 1999[6] states “[t]he average annual rate for non-fatal violent crime for all occupations is 12.6 per 1,000 workers. The average rate for physicians is 16.2; for nurses, 21.9; for mental health professionals, 68.2; and for mental health custodial workers, 69…Of psychiatrists responding to surveys, the average rate during their careers was 40%.”

Additionally, a significant percentage of medical residents are assaulted by patients. “Surveys of psychiatric residents found an assault rate ranging from 19% to 64%; rates of repeated assaults ranged from 10% to 31%.”[6] One survey of psychiatric residents found that the problem of patient violence directed at residents is “significant” and “many residents do not report incidents to program directors or to security, and … some respondents said they had been so severely affected by a violent incident that it caused them to reconsider their choice of specialty.”[7]

Possible consequences. Physical, psychological, and employment consequences.Patient violence against healthcare workers causes serious physical injuries and psychological trauma. Along with physical injury, victims of patient violence may suffer: “[s]hort- and long-term psychological trauma; fear of returning to work; changes in relationships with coworkers and family; feelings of incompetence, guilt, powerlessness; and fear of criticism by supervisors or managers.”[6] Employment consequences can include the cost of “increased turnover, absenteeism, medical and psychological care, property damage, increased security, litigation, increased workers’ compensation, job dissatisfaction, and decreased morale.”[8]

Malpractice liability. In some cases of patient violence, the treating psychiatrist could face liability under federal and/or state law. Lawsuits against a treating psychiatrist may allege negligence in assessing a patient’s potential for violence, implementing a proper treatment plan to prevent or reduce the risk to the patient and others, and/or properly warning potential victims of violence. Complaints related to a patient’s violence may also be made to the medical licensing board. As an employer, a psychiatrist may face allegations of failing to protect employees, other patients and visitors from violence by a patient.

Allegations against clinicians and healthcare employers are often based on the issue of “foreseeability,” e.g., did the clinician or healthcare employer know, or should have known that a risk existed and were reasonable steps taken to mitigate the risk? Risk assessments and specific actions based on such assessments, along with documentation of the process, are critical to reducing risk.

Reduce the risk. Identify and evaluate the risk. The psychiatrist’s assessment of a particular patient’s risk for violent behavior is part of the identification of the risk an individual poses to the clinician and others. Risk increases in situations when the patient is unknown and where a therapeutic alliance has not been established. Clinicians must stay professionally current with violence assessment literature and research.
A step that should not be overlooked is what the analysis of incidents reveals about the clinical needs of patients with violent behaviors. For example, are clinicians and staff adequately trained in recognition and early intervention to de-escalate potential violence? Is there an opportunity to educate and involve patients in avoiding and managing factors that lead to their threatening and violent behaviors? Does the analysis reveal other information that is useful for the clinical treatment of patients? Is that information incorporated into the patient’s treatment plan to improve both patient outcomes and safety for clinicians who will continue to treat the patient?

Reporting and documenting incidents of patient violence should be required for all incidents (e.g., physical assaults, verbal threats, abuse) and be consistent with a violence prevention policy and program.[9] According to Simon,[9] in a small practice, the reporting system may be less formal but requires ongoing and open communication among clinicians and staff about incidents and “near misses,” a clear understanding about the types of incidents to be reported, and an evaluation of incidents because “[e]very case of patient violence against clinicians provides lessons to be learned in safety management.”

Depending on the treatment setting, coordination and planning with building security, safety and risk managers, other clinicians and staff sharing offices and space is required.[10] There are several resources available that provide guidelines, checklists, and sample incident forms for establishing workplace violence prevention programs that can be adapted to psychiatric treatment settings. The International Association for Healthcare Security and Safety is one example.[10] Collaboration with your risk manager(s) will provide information about managing risks to avoid or reduce liability and increase safety.

Implement a safety plan and re-evaluate. Develop and implement a safety plan based on the evaluation of the risk factors with the highest risks being addressed first. Document the elements of the plan. Plans, policies, and procedures become outdated. Often, they are not followed as written and need regular revision and re-commitment to continue to be effective. A firm timeframe for re-evaluating and updating the plan should be established to avoid the pitfall of having a plan that is forgotten and no longer followed.

Patient violence towards clinicians requires both attention and preparation to reduce risk and provide for the safety of the clinician. Clinicians are encouraged to identify and evaluate risk in their practice settings. Once risk is identified, the clinician should implement a safety plan that is re-evaluated at intervals to ensure that it is up to date and being followed.

1. Weil. M. Vitaly Davydov of Montgomery, who killed psychiatrist, held in another slaying. The Washington Post. October 21, 2011. www.washingtonpost.com/local/vitaly-davydov-of-montgomery-who-killed-psychiatrist-held-in-another-slaying/2011/10/21/gIQAF7064L_story.html. Accessed February 14, 2013.
2. Moran M. Patient kills Virginia psychiatrist in his home office. Psychiatric News. August 19, 2011. http://psychiatryonline.org/newsarticle.aspx?articleid=115927. Accessed February 14, 2013.
3. Fenton J. Police: man upset over mother’s care at Hopkins kills her, himself. The Baltimore Sun. September 17, 2010. http://articles.baltimoresun.com/2010-09-17/news/bs-md-ci-shooting-hopkins-20100916_1_mother-hospital-staff-east-baltimore. Accessed February 14, 2013.
4. The Joint Commission. Preventing violence in the health care setting. Sentinel Event Alert. Issue 45, June 3, 2010. www.jointcommission.org/sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting_/. Accessed on February 14, 2013.
5. Hartley D, Ridenour M. Workplace violence in the healthcare setting. Medscape News. September 13, 2011. http://www.medscape.com/viewarticle/749441. Accessed February 14, 2013.
6. Occupational and Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R. Available at: http://www.osha.gov/Publications/osha3148.pdf. Accessed February 14, 2013.
7. Simon RI. Patient violence against health care professionals: safety and assessment. Psychiatr Times. March 3, 2011. http://www.psychiatrictimes.com/schizophrenia/content/article/10168/1813471. Accessed February 14, 2013.
8. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59–67. http://www.medscape.com/viewarticle/746092. Accessed May 30, 2012.
9. International Association for Healthcare Security and Safety (IAHSS). www.iahss.org Accessed February 14, 2013.

Additional Resources
1. Anderson A, West SG. Violence against mental health professionals: when the treater becomes the victim. Innov Clin Neurosci. 2011;8(3):34–92.
2. Chawla, J. Clinical safety in the neurology setting. Medscape Reference. August 24, 2011. Available at http://emedicine.medscape.com/article/1149218-overview. Accessed February 14, 2013.
3. ECRI Institute. Violence in healthcare facilities. Healthcare Risk Control. September 2005. www.ecri.org/Documents/RM/HRC_TOC/SafSec3.pdf. Accessed February 14, 2013. Go to “Products & Services” on the bar at the top of the page. Then choose “Free Resources” under the heading “Patient Safety, Quality and Risk Management” on the left side of the page. Click on “Reports and Advisories” and find “Violence in Healthcare Facilities” link under “Free Reports and Advisories”.
4. Emergency Nurses Association (ENA). A workplace violence toolkit. www.ena.org/IENR/ViolenceToolKit/Documents/toolkitpg1.htm. Accessed on February 14, 2013.
5. Sandburg, DA, NcNeil, DE, Binder RL. Stalking and threatening behavior by psychiatric patients toward clinicians. J Am Acad Psychiatry Law. 2002;30:221–229.

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