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Be prepared to respond to potential violence in your workplace :

April 26, 2017

You’re working in a busy emergency department (ED) or pediatric office, and the tension in the air is almost palpable. Your nurse approaches frantically signaling an escalating situation in exam room 5. The parents are irate and have become threatening toward staff. You try to remain calm, get a semblance of the facts, and with some degree of confidence and many sets of staring eyes, steadfastly approach the exam room. You take a deep breath, knock on the door and enter the room. Immediately, you feel physically threatened by two angry adults exhibiting limited self-control.

Having a step-by-step protocol to keep your employees, patients and others nearby safe will help you think clearly and function effectively when faced with these challenging situations. Such a protocol likely will reduce anxiety and may save lives.

Following are strategies to use in potentially violent situations in a pediatric office, health care clinic, ED or hospital setting.

Before you enter the room

  • Remove your stethoscope, necktie or scarf to keep them from being a strangulation risk. Empty your pockets of trauma shears and other sharp items that could be used as a weapon.
  • Notify an employee to stand by in case help must be summoned per the protocol.

Use clear, calm, caring communication

  • Upon entering the room, use a gentle and empathetic voice to express concern and a desire to help. Perhaps offer an apology in a calm voice. The apology is not intended to be an admission of guilt, but certain phrases can reduce tension. “I am very sorry that things have been so difficult today.” “I am so glad my nurse called me over.” “I would really like to try to help.” Other messages to convey are “You must be very concerned about your baby.” “I can see that you love her very much.” “Let’s see what we can do together to make things better.”
  • Offering a seat, a box of tissues or glass of water can be comforting and may diffuse the tension. Such gestures show you as a caretaker, not an adversary.
  • Use a qualified medical interpreter (in person or by telephone) for families with limited English proficiency. Use a family member to translate only if there are no other options and the situation is urgent. Speak slowly and clearly and maintain eye contact. Pause to allow the family an opportunity to process the information and respond.

Include experts, if available

  • If you’re in the ED, involving the child’s pediatrician who may have a longstanding relationship with the child and family can calm the situation.
  • Secure intervention from a clinical social worker or chaplain, if one is onsite.

Implement protocols and panic buttons

Instituting a clear protocol on what to do and how to do it is vital. Include key contact names and numbers for resources. Have the action steps on laminated cards and immediately available to employees.

Likewise strategically placed “panic buttons” to silently alert security, local police or protective services can save lives. In extreme situations, it is advisable to activate them before entering the patient’s room. Having someone poised to use them should the situation deteriorate is another option. Most hospitals have these devices. Since they are inexpensive, they can be installed in pediatric offices and clinics. Place them in several locations such as the front desk, physicians’ work room, laboratories and other central locations easily accessible to staff, but not curious children.

Contacting help, documenting incidents

Don’t hesitate to contact local police if a threat is made to you or another person or if any damage has been done to hospital or office property. These actions may be considered breach of peace, assault or destruction of property.

In some jurisdictions, a person is guilty of breach of the peace in the second degree when, with intent to cause inconvenience, annoyance or alarm, or recklessly creating a risk thereof in a public place: 1) engages in fighting or in violent, tumultuous or threatening behavior; or 2) assaults or strikes someone else; or 3) threatens to commit any crime against another person or that person's property; or 4) exhibits, distributes, posts up or advertises offensive, indecent or abusive matter concerning any person; or 5) uses abusive or obscene language or makes an obscene gesture; or 6) creates a hazardous or physically offensive condition by any act that such person is not licensed or privileged to do.

Depending on the jurisdiction, aggravated assault or aggravated battery may be charged when a person has the intention to cause physical injury with a weapon or dangerous instrument. A person can be charged if recklessly engaging in conduct that shows extreme indifference to human life. Depending on the charges, he or she may be incarcerated, fined, placed on probation or mandated to provide community service, if convicted.

Notify child protective services. Family members demonstrating aggression and violence may behave similarly in the privacy of their home, placing the child at increased risk of non-accidental trauma/child abuse.

Inform the proper person at your hospital. Many institutions have a zero tolerance policy for threats and may take legal action.

Create a narrative report about the incident. Follow up with a certified letter to the party involved indicating the facts of the situation, the outcome of the confrontation and the risks of future acts. If there are irreconcilable differences and you work in an ambulatory setting where there is the expectation of continuity of care, you may consider severing the doctor-patient relationship. Follow all relevant legal requirements for such terminations.

Document the incident in the patient’s medical record. The best predictive marker of impending violence is a history of violence. Flagging the record helps anticipate problems at future visits.

Dr. Santucci is a member of the AAP Committee on Medical Liability and Risk Management.


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