Joint Commission resources available to detect, prevent workplace violence

The news has been full of workplace violence incidents over the last decade, and the health care field is not immune to those tragic events. In 2015, a family member of a patient who died while receiving care from a cardiovascular surgeon shot and killed the surgeon at a hospital in Boston, MA. In 2017, a physician shot seven people—killing one—at a hospital in New York, NY, where he once was employed.

Defining workplace violence

Workplace violence is defined as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty,” according to the Centers for Disease Control and Prevention (CDC) National Institute for Occupational Safety and Health (NIOSH).1 Violence toward health care workers can take many forms, such as biting, kicking, punching, pushing, pinching, shoving, scratching, spitting, name calling, intimidation, threats, yelling, harassing, stalking, beating, choking, stabbing, and killing.2

Workplace violence occurs in all health care settings, but most incidents happen in the ED and inpatient psychiatric settings.

The Occupational Safety and Health Administration (OSHA) released a report in 2015, The Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, indicated that from 2011 to 2013, the annual number of workplace assaults was between 23,540 and 25,630. Of those assaults, between 70 and 74 percent happened in the health care or social service settings. The report also stated that assaults to health care workers comprised 10−11 percent of workplace injuries leading to time away from work, versus just 3 percent of injuries among all other private-sector employees.3

Workplace violence occurs in all health care settings, but most incidents happen in the emergency department (ED) and inpatient psychiatric settings.4

Resources available

To help stem the tide of workplace violence, The Joint Commission made available several tools on its Workplace Violence Prevention Resources web page. These resources include the following:

  • Sentinel Event Alert Issue 59: Physical and verbal violence against health care workers
  • Quick Safety Issue 47: De-escalation in health care
  • Blog posts on the topic
  • Research on improvement methods
  • Presentations
  • Federal and state resources

The Sentinel Event Alert includes an infographic that lists ways to identify factors associated with perpetrators of violence, which are as follows:

  • Altered mental status or mental illness
  • Patients in police custody
  • Long wait lines or crowding
  • Recipients of bad news about a diagnosis
  • Gang activity
  • Domestic disputes among patients or visitors
  • Presence of firearms or other weapons

The infographic also suggests that when violence occurs, staff should report it immediately to hospital leadership, security, and—if necessary—law enforcement.

Of perhaps greater importance to the practicing surgeon is the Quick Safety report on de-escalation, which lists several techniques to use as a first-line response to potential violence or aggression. These recommendations are as follows:5

  • Recognize aggressive patients or behaviors using assessment tools, such as the following:
    • STAMP (staring, tone and volume of voice, anxiety, mumbling, and pacing), a tool used to observe and document behaviors that could potentially lead to violence
    • OAS (overt aggression scale), which measures aggressive behaviors
    • BVC (BrØset violence checklist), which can be used to predict imminent violent behaviors
    • BRACHA (brief rating of aggression by children and adolescents), an instrument that scores 14 areas to assess risk of aggression
  • Intervene using the following tactics:
    • Use verbal communication techniques that are clear and calm. Staff should project a nonconfrontational attitude and avoid using abbreviations or health care terms.
    • Use nonthreatening body language when approaching the patient.
    • Approach the patient with respect and be supportive of their issues and problems.
    • Use risk assessment tools for early detection and intervention.
    • Provide staff training regarding the use of de-escalation techniques.
    • Respond to the patient’s expressed problems or conditions to help create a sense of trust with the health care professional.
    • Implement environmental controls, such as minimizing lighting, noise, and loud conversations.

Surgeons face critical and emergency situations daily, including encounters with victims of trauma or with family members who have received sad news about their loved ones, aggressive coworkers in stressful situations, and so on. We need to maximize our efforts to keep these men and women safe from the threat of workplace violence. For more resources, visit the Workplace Violence Prevention Resources web page.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication Number 96-100. Current Intelligence Bulletin 57. Violence in the workplace. July 1996. Available at: Accessed January 30, 2020.
  2. The Joint Commission. Sentinel Event Alert, Issue 59: Physical and verbal violence against health care workers. Available at: Accessed January 30, 2020.
  3. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers (OSHA, 3148-04R). 2015. Available at: Accessed January 30, 2020.
  4. Security Industry Association and International Association of Healthcare Security and Safety Foundation. Mitigating the risk of workplace violence in health care settings. August 2017. Available at: Accessed January 30, 2020.
  5. The Joint Commission. Quick Safety, Issue 47: De-escalation in health care. Available at: Accessed January 30, 2020.

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