Violence No Longer Stops Outside the Doors to the Hospital!


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Lisa Pryse, President-Elect IAHSS and President, ODS Healthcare and Chief of Company Police delivered this presentation at the 2012 Australian Hospital & Healthcare Security & Safety Conference. The conference is a fantastic opportunity to network with hospital security managers, OH&S unit coordinators, senior nursing and management staff of hospital departments, namely emergency departments and mental health units In its 6th annual edition the conference has been rebranded Safe & Secure hospitals to reflect industry feedback we have received through our research calls. For more information, please visit:

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Violence No Longer Stops Outside the Doors to the Hospital!

  1. 1. Violence No Longer Stops Outside The Doors To The Hospital! 5th Annual Hospital and Healthcare Security & Safety Conference October 26, 2012 Lisa Pryse, CHPA, CPP President, ODS Healthcare Security/Company Police ASIS International Healthcare Council and President-Elect, IAHSS
  2. 2. ACT definition targets the impact of violence as criteria in a very broad sense: “Workplace Violence is any action or incident which causes physical or psychological harm to another person” ACT Definition of Workplace Violence:
  3. 3.  Abusive language, intimidation, assault, fighting, or other violent acts displayed by employees, co- workers, management, patients, visitors, or other parties which may cause emotional or physical intimidation or harm. US OSHA Definition of Workplace Violence:
  4. 4.  TYPE I : The aggressor has no legitimate relationship to the workplace and the main objective is to commit a robbery (cash, drugs) or other criminal act. (“External” violence).  TYPE II : The aggressor is the recipient or the object of a service provided by the affected workplace or the victim, e. g. a client, patient. This may include also relatives or friends of the clients. (“Client initiated” violence).  TYPE III : The aggressor has an employment-related involvement in the work setting. Usually it is a another employee , a co-worker, a supervisor, a boss, a student (“internal” violence). Guidelines on Workplace Violence in the Health Sector Comparison of major known national guidelines and strategies: UK, Australia, Sweden, USA (OSHA and California)
  5. 5. Video: “Flash Point For Healthcare” Recognizing and Preventing Violence in the Healthcare Community By The Center of Personal Protection and Safety
  6. 6.  The employee survey results suggest that under- reporting of aggression is a significant problem.  They also suggest that many employees do not believe management understands the aggression problems and are not committed to reducing the risks of aggression. Heads of Workplace Safety Authorities (HWSA) Australia and New Zealand “Aggression Management in Hospitals Intervention and Compliance Campaign – 2011”
  7. 7. The National OHS Strategy 2002 – 2012 required a reduction in the incidence of work related injury by 40% by June 2012. To achieve this 10 year target, a 5% to 6% annual reduction in the rate of injury was required. Heads of Workplace Safety Authorities (HWSA) “Aggression Management in Hospitals Intervention and Compliance Campaign - 2011
  8. 8. However, data on the number of national worker’s compensation claims show that between 2001 and 2008: - the total number of national claims in Hospitals decreased by only 6% - the number of “assault by other person” national claims in Hospitals increased by 58% Heads of Workplace Safety Authorities (HWSA) “Aggression Management in Hospitals Intervention and Compliance Campaign – 2011”
  9. 9.  More assaults (greater than 50%) occur in healthcare and social service industry than in any other industry (US Department of Labor).  Working in healthcare is considered to be the third most dangerous job in the US.  CDC and NIOSH has identified nursing as one of the most dangerous occupations in the US (Massachusetts Nursing Association Legislative Agenda 2000). Statement of the Problem for Healthcare
  10. 10.  Diverse Population • Can’t turn anyone away • Ambulatory & non-Ambulatory • Patients, Family, Friends, Vendors, Staff • Microcosm of a City  Open Access to Public • 24/7 • Multiple Access Points  Duty to Provide Care & Protect the Vulnerable  Prescriptive Culture  Heightened Anxiety and Frustration Levels • Crisis Mentality • Staffing Shortages • Unpredictable  Last Place People Want to Be… Unique Environmental Considerations for Healthcare
  11. 11.  Persistent perception in the healthcare industry that assaults are a part of the job .  Nurses often fail to identify violent acts as actual violence and there is a tendency to minimize the severity of violence. Statement of the Problem for Healthcare Internationally
  12. 12.  Prevalence of various types of weapons  Increasing number of acute and chronically mentally ill patients now being released without follow up care  The availability of drugs or money in hospitals or clinics (Point of Service payment)  Public building - unrestricted movement in much of building Risk Factors
  13. 13.  Drug or alcohol abusers  The presence of street gangs in some locations  Trauma patients many times are victims of violence  Distraught family members  Frustrated clients due to long waits (what is the definition of a long wait?) Risk Factors
  14. 14.  Domestic disputes which may spill over into the work environment  Low staffing levels during periods of increased activity  Isolated work with clients  Remote work locations with little security or access to communication devices Risk Factors
  15. 15.  Lack of staff training in recognizing and managing escalating hostile and assaultive behavior  Poor conflict resolution and communication skills of management  Lack of feedback to employees and inconsistent implementation of policies which may lead to disgruntled employees Risk Factors
  16. 16.  Physical harm to staff, visitors, patients  Psychological harm  Low morale  Increased job stress  Increased staff turnover  Reduced trust  Creation of a hostile working environment  Financial implications  Legal implications Potential Impact
  17. 17. “Inquiry Into Violence And Security Arrangements In Victorian Hospitals And, In Particular, Emergency Departments – December 2011” Principles Informing The Recommendations:  1. The Committee believes that all hospital staff are entitled to a safe and secure working environment that is free of all forms of violence.  2. The Committee recognises that hospital administrations face a complex challenge in reducing violence in especially in some large emergency departments (EDs).  3. The law should support clinical and security staff in their work environments. Parliament of Victoria Drugs and Crime Prevention Committee
  18. 18. Principles Informing The Recommendations: 4. The Committee believes that in addressing violence and security issues in Victorian hospitals: a) A ‘one size fits all’ approach does not address the specific issues, needs and requirements of individual hospitals and health facilities. b) Proactive policies based on prevention strategies are the key to addressing violence in hospitals. Parliament of Victoria Drugs and Crime Prevention Committee
  19. 19. Principles Informing The Recommendations: 4. (continued) c) A holistic and tailored approach is required that meets the specific requirements of each hospital. Such a holistic approach should draw upon strategies including: • strong leadership, support and encouragement by the senior management team at the hospital. Parliament of Victoria Drugs and Crime Prevention Committee
  20. 20. Principles Informing The Recommendations: 4. (4c continued) • appropriate policies and infrastructure that promote a ‘zero tolerance’ approach to violence towards…. all persons located in the hospital premises or environment. • accredited comprehensive education and training programs to address violent behaviour in hospitals for all. Parliament of Victoria Drugs and Crime Prevention Committee
  21. 21. Principles Informing The Recommendations: 4. (4c continued) • approaches that recognise the specific factors that contribute to hospital violence and promotes strategies to address these. • environmental and design strategies that address the situational factors that may exacerbate violence in the hospital setting, particularly the emergency department. Parliament of Victoria Drugs and Crime Prevention Committee
  22. 22. Principles Informing The Recommendations: 4. (continued) d) Strategies to prevent and address violence in hospitals are most effective when clinical staff, security staff, management and external workers work collaboratively as part of a team. Parliament of Victoria Drugs and Crime Prevention Committee
  23. 23. Principles Informing The Recommendations: 4. (continued) e) Effective security strategies to prevent and address violence in hospitals are underpinned by a ‘patient focused’ approach that draws on interpersonal skills to defuse, minimise and manage aggressive behaviour. f) Effectively addressing violence in the hospital setting requires uniform reporting procedures and data collection across the Victorian hospital system. Parliament of Victoria Drugs and Crime Prevention Committee
  24. 24. Principles Informing The Recommendations: 5. The Committee believes as a general principle that security staff should be licensed specialists in the area of hospital security and appointed by individual hospitals as determined by the hospital’s specific needs. 6. The Committee believes that firearms should not be used as a security measure in Victorian hospitals by security personnel. Parliament of Victoria Drugs and Crime Prevention Committee
  25. 25. Principles Informing The Recommendations (cont’d): 7. The Committee believes that as a general principle, capsicum spray and tasers should not be used as a security measure in Victorian hospitals, by security personnel. However, individual hospitals should have the power to decide what other forms of restraint and security mechanisms should be employed. Parliament of Victoria Drugs and Crime Prevention Committee
  26. 26. Discussion?? Parliament of Victoria Drugs and Crime Prevention Committee
  27. 27. Engineering Controls  Worksite Analysis  Department designs  Security measures must be considered when planning renovation or new construction  Security Devices  Access Control and other security hardware  Cameras Program Development
  28. 28. Administrative Controls  Policies and Procedures  Training Program Development
  29. 29.  Security Management Plan  Management of Access Control  Employee Administrative Inspections  Guidelines for Management of Potentially Threatening Letters, Packages, Parcels  Protection of Patients in Custody  Security Risk Patient Protection Plan  Weapons on Property  Management of Sexual Harassment Important Policies and Procedures
  30. 30.  Workplace Violence Response Plan  Civil Disturbance Response Plan  Hostage Response Plan  Bomb Threat Response Plan  Threat Response Plans  High Security Alert Response Plan  Domestic Violence Response Plan  Clients and employees Important Policies and Procedures
  31. 31.  Provide screening and resources.  When an employee has a domestic order that lists any healthcare facility as being protected areas, the employee is to report the information to the hospital security department.  Information will be managed with sensitivity to confidentiality  Information will be used to develop a personal safety plan to protect employee and co-workers, e.g. escorts to vehicles, rotating routes of travel to work, department safety plan, etc. Domestic Violence
  32. 32.  All threats are to be taken seriously.  All threats are to be reported to one’s supervisor.  Threat Report Form.  Employee Injury/Illness form if an actual injury was sustained.  Multidisciplinary Threat Assessment/Management Team.  Security Risk Plan. Management of Threats
  33. 33.  Executive endorsement  Must be at all levels of the organization  Mandatory for high risk departments  Multiple topics Training Programs
  34. 34.  Violence in the Workplace Work Group (Threat Assessment Team)  Development of policies and procedures  Data analysis of events / trends  Development of action plans  Training Program Development  Crisis Intervention Team Program Oversight
  35. 35. IAHSS Security Design Guidelines for Healthcare Facilities (
  36. 36. Additional IAHSS Guidelines for Healthcare Facilities  Violence in Healthcare  Targeted Violence  Forensic Patient Security  Security Officer Staffing & Deployment  Searching Patients and Patient Areas for Contraband  Security Response to a Critical Incident  Restricting Weapons in the Healthcare Environment  Restricted Access  Security in the Emergency Care Setting  Behavioral/Mental Health General
  37. 37.  Director of Security should be educated and well credentialed in the field of healthcare security (IAHSS, ASIS, etc.) as well as leadership in general.  Security officers should be trained in healthcare specific security issues , non-violent crisis intervention/de escalation techniques, state laws with oversight for security officers, personal defense tactics, as an IAHSS Security Officer, etc .  Security Department should offer ongoing classes for hospital staff (Personal Defense for Women, etc.). What Role Should the Security Department Play?
  38. 38.  Consider an ongoing (quarterly) facilitated team meeting between the Security Department and the Emergency Department (where most of the reported acts of violence originate).  Consider specially trained security officers to staff the Emergency Department as well as any inpatient Behavioral Health Unit.  The Security Department should be held to as high a standard as any other department in the organization and thus allowed to participate in various patient care, etc. initiatives. What Role Should the Security Department Play?
  39. 39. Violence Spectrum
  40. 40.  Awareness Mindset Critical • CANNOT Ignore Behaviors of Concern  Do NOT Go Away  Escalation Likely  Recognition • Intervene Early and Appropriately  Alert supervisors to concerns  Report ALL incidents • Nothing is insignificant Violence Spectrum
  41. 41. There is a balance which must be maintained between security of the facility and accessibility….. Ultimate Workplace Violence Incident: Active Shooter Prevention and Response
  42. 42. Who is the Active Shooter?
  43. 43.  An armed person who has used deadly force on other persons and continues to do so while having unrestricted access to additional victims, different from hostage situations. Sheriff’s Office Policy and Procedure Manual. Colorado Springs, Colorado, USA: El Paso County Sheriff's Office. 2004-01-01. Active Shooter Definition
  44. 44. The U.S. Department of Homeland Security Active Shooter Book recommends: 1. Evacuate 2. Hide out 3. Take action against the active shooter, as a last resort. Ultimate Workplace Violence Incident: Active Shooter Prevention and Response
  45. 45.  Date: October 31, 2011  Victims: 0 killed, 0 wounded  Offenders: 66 year old patient  Incident: Australian Doctor Discovers Gun In Prosthetic Leg Of St. Vincent’s Hospital Patient Sydney, Australia St. Vincent's Hospital in Lockdown After Gun Found With Patient on Level 9
  46. 46.  Date: April 20, 1999  Victims: 13 killed, 23 wounded  Offenders: Dylan Klebold 17, Eric Harris, 18  Incident: Active Shooter Columbine High School Littleton, CO Dylan Klebold Eric Harris
  47. 47.  Date: April 16, 2007  Victims: 32 killed, 17 injured  Offender: Seung Hui Cho  Incident: Active Shooter Virginia Tech, Blacksburg, VA Seung Hui Cho
  48. 48.  Date: February 14, 2008  Victims: 6 killed, 18 injured  Offender: Steven Kazmierczak  Incident: Active Shooter Northern Illinois, DeKalb, IL Steven Kazmierczak
  49. 49.  Date: November 5, 2009  Victims: 13 killed, 30 wounded  Offender: Nidal Malik Hasan  Incident: Active Shooter Fort Hood, Killeen, TX Nidal Malik Hasan
  50. 50.  Date: March 27, 2008  Location: Columbus, GA  Shooter: Charles Johnston  Victim(s): 3 Deaths  Hospital Area : 5th Floor  Event: A 63-year-old retired school teacher entered the hospital at 3:30 PM with a gun, went to the 5th floor, and opened fire on hospital workers. His mother had died of natural causes in 2004 on the 5th floor. One of the victims was a truck driver he encountered in the parking deck. Shooter bore a grudge against a nurse over his mother’s treatment. Columbus Regional Medical Center Shooting (aka Doctors Hospital)
  51. 51.  Date: November 26, 2008  Location: Soldotna, AK  Shooter: Joseph A. Marchetti  Victim(s): 2 Deaths/1 Injury  Hospital Area : Imaging Dept/ Main Corridor Event: A former employee who lost his job as a digital imaging technician a day earlier entered the hospital shortly before 10:00 AM armed with a .223 caliber semiautomatic rifle and a .9mm pistol. He opened fire on his ex-supervisors, killing one and wounding the other. During the 40-minute shooting spree, the gunman, after shooting his first victim, spotted him later sitting in a wheelchair bleeding, and shot him again. Central Peninsula General Hospital Shooting
  52. 52.  Date: March 29, 2009  Location: Carthage, NC  Shooter: Robert Stewart  Victim(s): 8 Deaths, 3 Wounded (including shooter)  Event: A 45-year-old gunman burst into a North Carolina nursing home and started shooting, barging into the rooms of terrified patients, sparing some from his rampage, without explanation, while killing seven residents and a nurse caring for them. Stewart’s ex- wife, who was married to him for 15 years, said he had violent tendencies. Victims ranged in age from 39 (nurse) to 98. Pinelake Health & Rehab Center Shooting
  53. 53.  Date: April 16, 2009  Location: Long Beach, CA  Shooter: Mario Ramirez  Victim(s): 3 Deaths (Gunman)  Hospital Area : Rear of Hospital Pharmacy  Event: A pharmacy technician showed up for work at 11:47 AM brandishing two handguns; killed his boss and another manager and then fatally shot himself. All three men worked in the outpatient pharmacy. There were layoffs the previous month, but none other projected. A friend felt he was concerned about losing his job. Long Beach Memorial Medical Center Shooting
  54. 54.  Date: August 16, 2010  Location: Las Vegas, NV  Shooter: Susan Kapfer  Victim(s): 2 Deaths  Hospital Area : Patient Room  Event: Susan Kapfer, 50, shot and killed her husband Michael, 55, at 4:40 AM at Las Vegas' Valley Hospital before killing herself. She had spent the night in his private room. Her husband suffered from deteriorating health. She left a suicide note in her car dated three days before. Note ended, “They (hospital) just don’t care.” Valley Hospital Shooting
  55. 55.  Date: September 16, 2010  Location: Baltimore, MD  Shooter: Paul Warren Pardus (aka Warren Leo Davis)  Victim(s): 2 Deaths/1 Injury  Hospital Area : Patient Room  Event: Dr. Cohen was giving the 50-year-old man some news about the care and condition of his mother just outside the doorway of her room. The gunman grew "over-whelmed" when the doctor told him about the care of his mother and pulled a small semi-automatic handgun from his waistband. Johns Hopkins Hospital Shooting
  56. 56.  Date: September 29, 2010  Location: Omaha, NE  Shooter: Jeffery Layten  Victim(s): 1 Death/3 Injuries  Hospital Area : Front Lobby  Event: A 39-year-old man led police on a car chase, and then opened fire hours later at an Omaha hospital. Police report he was wanted for domestic assault and terroristic threats. A friend reported he was distraught about his marital problems and didn’t want to live anymore. Creighton University Medical Center Shooting
  57. 57. Nature of violence •Violence often results from frustration •Conflicting parties usually feel threatened and compelled to protect their positions at all costs. • Violence, many times, results from a breakdown in communications • The key is to identify the source of the frustration and open a line of communication There is no profile of an Active Shooter
  58. 58. Nature of violence •Not a single variable capable of predicting violence •Best predictor of future behavior is past behavior •Unaddressed disruptive behaviors will either continue and/or increase There is no profile of an Active Shooter
  59. 59. 1. Long history of frustration, failure, and a diminished ability to cope with life’s disappointments 2. Externalizes blame 3. Lack of emotional support from family and friends 4. Suffer a precipitating event they view as catastrophic 5. Access to a weapon powerful enough to satisfy need for revenge James Alan Fox Northeastern University Five Characteristics of Mass Killers
  60. 60.  Single male shooter with more than one firearm  Daylight hours  In a building  Well populated location  Shooting over in 2 to 3 minutes  Initially target specific people  If targeted people unavailable or killed, will target people at random  Will likely take own life Study of Active Shooter Incidents
  61. 61.  Perpetrators of targeted acts of lethal violence often engage in covert and overt pre-attack behaviors.  Perpetrators: Consider Plan Prepare Share Move from ideas to actions Targeted Violence Process
  62. 62.  Rings of Security  Hot Zone – Immediate Danger  Warm Zone – Intermediate Danger  Cold Zone – Remote Danger  The Healthcare Action ACRONYM  4 A’s: Accept, Assess, Act, Alert  Equivalent of “Race and Pass” Active Shooter Survival in a Healthcare Setting
  63. 63. “No Plan Leads to the Wrong Plan”  Independent, proactive measures can be dangerous  Risky self protection vs. team approach  Doubtful effectiveness in future  Moral obligation not met by organization Dangers of Untrained Individuals
  64. 64. Normalized Behavior in Stressful Situations  Plan in place  Persistence in the face of adversity  Protection of self and others  Proactive stance  Post situation recovery  Moral obligation met by organization Benefits of Training -
  65. 65. Extreme Danger Gap Onset of Violence Arrival of First Responders Immediate Responders: • Need to be Prepared • Need to be Empowered • Need to be Supported
  66. 66. 1. Workplace violence is a serious threat for all healthcare facilities (HCFs) and requires proactive steps to be taken to prevent and mitigate risks associated with violence. A situation involving a person who has or is threatening to use a firearm, and may be moving from one location to another on campus, requires a specific response protocol by all HCFs. International Association of Healthcare Security and Safety (IAHSS) Active Shooter Response Guideline
  67. 67. Summary of Points: 2. A multidisciplinary team should be appointed by the HCF to designate, in writing, its plan for responding to an active shooter on campus in coordination with local law enforcement. 3. Communication procedures should be established that includes the creation of a specific announcement (emergency code or plain language) and procedure to institute a response to an active shooter situation. International Association of Healthcare Security and Safety (IAHSS) Active Shooter Response Guideline
  68. 68. Summary of Points 4. The HCF should have a timely campus-wide notification system to alert staff to the threat of an active shooter. The mechanisms should include multiple modes of notification intended to reach all persons inside the facility and on its grounds. These may include overhead pages, text (SMS) messaging, digital displays, e-mails, intercoms, call boxes, popup messages, or other notification methods. International Association of Healthcare Security and Safety (IAHSS) Active Shooter Response Guideline
  69. 69. Summary of Points 5. Employees and staff should be educated on their awareness, reporting of and response to an active shooter. Specific procedures should be established for the initial response of staff or anyone in the immediate vicinity of an active shooter. International Association of Healthcare Security and Safety (IAHSS) Active Shooter Response Guideline
  70. 70. Summary of Points 6. Activation of the active shooter response plan should include immediate notification to law enforcement. 7. Activation of the active shooter response plan may include specified actions (listed in guideline). 8. Upon conclusion of an active shooter event, the HCF should announce an “all clear” only after law enforcement has indicated the environment is safe. 9. Active shooter drills should be conducted periodically to exercise the plan and the response of law enforcement. International Association of Healthcare Security and Safety (IAHSS) Active Shooter Response Guideline
  71. 71. Additional dynamics exist in the healthcare environment: duty to protect the patient. Ultimate Workplace Violence Incident: Active Shooter Prevention and Response
  72. 72. Video: “Shots Fired For Healthcare” Guidance for Surviving an Active Shooter Situation in the Healthcare Community By The Center for Personal Protection and Safety
  73. 73. The Center for Personal Protection & Safety ( has developed two videos specific for healthcare: Shots Fired: Healthcare; Flashpoint: Prevention Strategies in Healthcare. Ultimate Workplace Violence Incident: Active Shooter Prevention and Response
  74. 74. Thank you! 804-389-0208