Topic Collection Cover Page

Workplace Violence
Topic Collection
January 6, 2022

Topic Collection: Workplace Violence

Workplace violence may occur with minimal or no advanced notice and can have devastating consequences. It is vitally important for emergency planners to have policies and procedures to prevent, mitigate and respond to incidents of workplace violence. Healthcare settings have unique vulnerabilities and obligations to patients and the public which require careful planning, education, and exercising. The resources in this Topic Collection highlight some of the most current information and guidance that can assist emergency managers tasked with developing and maintaining workplace violence prevention programs and other guidelines to ensure the resiliency of their facilities.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

Must Reads


Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
The authors describe a three-phase approach used by responders to a mass shooting event that happened in Minneapolis (MN) in 2012: Enter, Evaluate, and Evacuate (or 3 Echo). 3 Echo stresses early, multi-disciplinary coordination and teaches participants about unified command, swift victim evacuation, how to establish corridors of safety, and other critical skills.
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Centers for Disease Control and Prevention. (2021). Workplace Violence Prevention for Nurses.
This short course is based on Occupational Safety and Health Administration guidance and can help healthcare providers understand, prevent, prepare for, and respond to workplace violence. Participants can earn continuing education credits.
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Division of Workers’ Compensation and Workplace Safety. (n.d.). Health Care Facilities and Workplace Violence Prevention. (Accessed 10/22/2021.) Texas Department of Insurance.
This brochure can increase healthcare facility employee and employer awareness of the risk factors for violence in these settings. The brochure also includes strategies for reducing exposure to risks.
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This webpage includes resources that can help an emergency department manager or designated team leader develop and implement a comprehensive plan that addresses needs related to managing violent behaviors in the emergency department and protecting staff.
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Violence in healthcare facilities presents a growing and significant challenge to patients, providers, support staff, and visitors. Hospital emergency departments (EDs)—where doors are always “open”—are frequently the site of violence, which is either carried over from external conflict or perpetrated by patients (and/or their loved ones) against healthcare workers. This article highlights variables that contribute to challenging situations and strategies hospitals can use to prevent them, keeping patients and staff as safe as possible.
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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
The Hartford Consensus suggests that first responders to an active shooter scene should apply the actions in the acronym THREAT: 1) Threat suppression, 2) Hemorrhage control, 3) Rapid Extrication to safety, 4) Assessment by medical providers, and 5) Transport to definitive care.
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Kirkwood, S., and Teitsort, K. (2012). Violence Against EMS Providers: What Can We Do About It? EMSWorld.
The authors provide an overview of violence against emergency medical services providers. They stress the need for: better reporting; changes in organizational culture to make it more acceptable to report; and changes in training responders on how to protect themselves from violent individuals.
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Kowalenko, T., Cunningham, R., Sachs, C.J., et al. (2012). Workplace Violence in Emergency Medicine: Current Knowledge and Future Directions. (Abstract only.) Journal of Emergency Medicine. 43(3):523-31.
The authors reviewed literature on emergency department workplace violence and found that staff face higher risk of physical assaults compared to other health settings. They offer suggestions for preventing and reducing violent incidents.
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This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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Morken, T., Johansen, I. and Alsaker, K. (2015). Dealing with Workplace Violence in Emergency Primary Health Care: A Focus Group Study. BMC Family Practice. 16:51.
This study explores how emergency primary health care organization personnel have dealt with threats and violence in the workplace.
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Occupational Safety and Health Administration. (n.d.). Workplace Violence Prevention - Health Care and Social Service Workers. (Accessed 10/22/2021.) U.S. Department of Labor.
This presentation provides an overview of the Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers published by the Occupational Safety and Health Administration (“OSHA 3148”). (Note: topics are listed alphabetically; users must scroll down to access workplace violence resources.)
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Occupational Safety and Health Administration. (2015). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. U.S. Department of Labor.
This document is an update of the Occupational Safety and Health Administration’s 1996 and 2004 voluntary guidelines for preventing workplace violence for healthcare and social service workers.
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Occupational Safety and Health Administration. (2015). Workplace Violence. U.S. Department of Labor.
This website provides information on the extent of violence in the workplace, assessing the hazards in different settings and developing workplace violence prevention plans for individual worksites.
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This article provides an overview of workplace violence, highlights risk factors that contribute to healthcare workplace violence, and summarizes related legislation and policies. It also highlights strategies and guidance healthcare staff and security partners can incorporate into their coordinated healthcare workplace violence plans.
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Stene, J., Larson, E., Levy, M., et al. (2015). Workplace Violence in the Emergency Department: Giving Staff the Tools and Support to Report. The Permanente Journal. 19(2).
This research study examines the results of a workgroup that developed a workplace violence survey and reporting tool.
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Trotto, S. (2014). Workplace Violence in Health Care. Safety and Health Magazine.
The author discusses workplace violence in healthcare settings and provides an overview of proposed legislation to protect healthcare workers.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Active Shooter Planning and Response in a Healthcare Setting.
This document provides active shooter guidance tailored specifically to the healthcare setting.
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U.S. Department of Health and Human Services; U.S. Department of Homeland Security; U.S. Department of Justice, Federal Bureau of Investigation; and Federal Emergency Management Agency. (2014). Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans.
This document gives healthcare facility emergency planners, executive leadership, and others involved in emergency operations planning assistance with planning for active shooter incidents.
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U.S. Department of Labor. (n.d.). Department of Labor Workplace Violence Program. (Accessed 10/22/2021.)
This document comprehensively describes the Department of Labor’s Workplace Violence Program including policies and procedures, identification, prevention and response.
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The Occupational Safety and Health Administration lists violence prevention guidelines for the following healthcare settings: hospitals, residential and non-residential treatment, community care, and field work. The authors of the report also list the five “building blocks” for developing an effective prevention program: management commitment and employee participation; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation.
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Active Shooter/Mass Shooting


American Hospital Association. (2021). Active Shooter Incidents in Health Care Settings.
This webpage includes links to various resources (e.g., webinars, podcasts, and case studies) on preparing for and responding to active shooter incidents in healthcare facilities.
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Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
The authors describe a three-phase approach used by responders to a mass shooting event that happened in Minneapolis (MN) in 2012: Enter, Evaluate, and Evacuate (or 3 Echo). 3 Echo stresses early, multi-disciplinary coordination and teaches participants about unified command, swift victim evacuation, how to establish corridors of safety, and other critical skills.
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In this summary of active shooter events, the authors share research findings (e.g., location, shooter and victim demographics) and emergency healthcare training and equipment implications for first responders (primarily law enforcement in these incidents).
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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Federal Bureau of Investigation. (n.d.). Active Shooter Incidents. (Accessed 6/29/2021.) U.S. Department of Justice.
This webpage describes the incidents and the agency’s efforts at prevention. The page provides links to in-depth reports, statistics, guides, after-action reports of recent incidents (including the school shooting at Sandy Hook Elementary), planning guides, and the video geared towards the general public: “Run, Hide, Fight.”
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This article summarizes a presentation on an active shooter incident that took place in the parking lot and inside of Mercy Hospital’s (Chicago) emergency department. The author lists five takeaways and provides links to related resources.
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* Gao, H. and Adashi, E. (2015). An Analysis of Active Shooters in the Hospital Setting, 2000-2015. Alpert School of Medicine at Brown University.
This infographic illustrates the frequency of active shooter incidents and lists location demographics and motive and disposition of perpetrators. The authors found that more shootings are happening inside of healthcare facilities, the most common motive is a “grudge,” and incidents are often perpetrated by inmates trying to escape.
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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
The Hartford Consensus suggests that first responders to an active shooter scene should apply the actions in the acronym THREAT: 1) Threat suppression, 2) Hemorrhage control, 3) Rapid Extrication to safety, 4) Assessment by medical providers, and 5) Transport to definitive care.
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Kelly, R. (2012). Active Shooter Recommendations and Analysis for Risk Mitigation. New York City Police Department.
This report provides summary and detailed information for 281 active shooter events and includes related policy and other recommendations.
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Leppert, J., Wren, S., and Bergman, J. (2019). Operating Room Preparedness for Active Shooter Events. Surgery. 167(2):510-511.
The authors describe hearing an alarm for an active shooter while they were in the middle of performing a robotic partial nephrectomy for a patient with renal cell carcinoma. They listed some of the ethical dilemmas the faced regarding next steps (i.e., abort or continue the surgery). A subsequent review of their facility’s incident action plan found no mention of these incidents in the operating room; the authors encourage better planning that “can allocate operating room resources and disseminate critical information while considering the tensions specific to the delivery of surgical care in the operating room.”
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Los Angeles Sheriff's Department. (2015). Surviving an Active Shooter.
This video depicts active shooter scenarios and shares strategies for responding to and surviving such events.
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This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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The authors provide active shooter planning guidance under five main categories: Pre-Incident Prevention and Preparation, Management During and Incident, Post Event Management, Safety Tips for Personnel and Additional Resources.
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* Newton, E. (n.d.). Hospital Violence Active Shooter. (Accessed 10/22/2021.)
This speaker defines active shooter incidents, illustrates the problem with recent data, outlines the planning process for hospitals, and shares information related to active shooter exercises—general and specific to her healthcare organization. (Copy and paste this link into your browser to access the PPT presentation: http://www.wsha.org/wp-content/uploads/Disaster-Readiness-5-27-Active-Shooter-Eileen-Newton.pptx)
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Ready Houston. (2012). Run, Hide, Fight: Surviving an Active Shooter Event. The City of Houston Mayor’s Office of Public Safety and Homeland Security.
This short video depicts active shooter scenarios and demonstrates how those affected can increase their chances of survival. Though developed for Houston, it does not contain jurisdiction-specific information, allowing it to serve as a valuable resource for all.
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* Schwerin D., Thurman, J., and Goldstein, S. (2021). Active Shooter Response. StatPearls.
The authors provide comprehensive overviews of active shooter incidents and these incidents in healthcare facilities. They highlight response options, training considerations, and other considerations healthcare emergency planners can incorporate.
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The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. (2013). Active Shooter and Intentional Mass-Casualty Events: The Hartford Consensus II. Bulletin of the American College of Surgeons.
This resource summarizes findings from a meeting of The Hartford Consensus on active shooter and mass casualty events. The group emphasizes the need for on-scene collaboration between emergency medical services and law enforcement, and highlights the supportive role that uninjured bystanders can also play in the response effort.
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The National Association of Emergency Medical Technicians. (2015). TCCC Guidelines and Curriculum.
The principles of Tactical Combat Casualty Care (TCCC) can also be applied by first responders when responding to bomb and mass shooting incidents. TCCC has three goals: 1) treat the casualty, 2) prevent additional casualties, and 3) complete the mission.
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Active Shooter Planning and Response in a Healthcare Setting.
This document provides active shooter guidance tailored specifically to the healthcare setting.
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* U.S. Department of Health and Human Services; U.S. Department of Homeland Security; U.S. Department of Justice, Federal Bureau of Investigation; and Federal Emergency Management Agency. (2014). Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans.
This document gives healthcare facility emergency planners, executive leadership, and others involved in emergency operations planning assistance with planning for active shooter incidents.
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U.S. Department of Homeland Security. (2015). Active Shooter Preparedness.
This webpage includes information on the subject including tips for what to do in an active shooter situation, and links to webinars, reports, training events, and informational materials (e.g., pamphlets, posters and wallet cards) in English and Spanish.
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U.S. Department of Homeland Security. (2017). First Responder.
This webpage includes links to resources geared towards first responders who may be called to an active shooter situation. Users can access "how to respond" resources (e.g., booklets, pamphlets, fact sheets--in several languages), videos, reports, and other items that can be helpful in developing plans for and responding to these types of incidents.
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This brief action guide highlights potential warning signs and response and mitigation strategies specific to an active shooter situation in a healthcare facility.
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Education and Training


Centers for Disease Control and Prevention. (2021). Workplace Violence Prevention for Nurses.
This short course is based on Occupational Safety and Health Administration guidance and can help healthcare providers understand, prevent, prepare for, and respond to workplace violence. Participants can earn continuing education credits.
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Garrett, T. (2013). Safety in the Workplace. Alabama Department of Public Health.
This webinar is geared toward healthcare professionals. The speaker discusses how to identify potential risk factors in the work setting and develop a response plan in the event of a violent situation.
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Health Care Association of New Jersey. (2014). LTC Shots Fired Tabletop Exercise Situation Manual.
This tabletop exercise can help healthcare facility executives and team members address key active shooter issues through a series of facilitated discussions. The completed Situation Manual contains detailed objectives, scenario information, and discussion questions that may be referenced by other organizations when designing a similar exercise.
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Maguire, B., Gerard, D., Cormier, S., et al. (2021). Changing Threat Environment for EMS and Fire Personnel in the US. International Association of EMS Chiefs.
This two-hour webinar features speakers discussing the challenges, problem, and policy responses specific to violence against against first responders (including how the risk has recently increased for fire and medical first responders(
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This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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Mount Sinai Health System. (2020). Armed Intruder/Active Shooter Training Module.
This free short training module provides healthcare providers and other staff with an overview of strategies and protocols for an armed intruder/active shooter incident. Speakers describe the "run-hide-fight" and "secure-preserve-fight" approaches and share "Stop the Bleed" basics, a video for how to apply a tourniquet, and resources for managing stress. Though this training was created by the Mount Sinai health system, it is applicable to other healthcare providers and healthcare systems.
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* Schwerin D., Thurman, J., and Goldstein, S. (2021). Active Shooter Response. StatPearls.
The authors provide comprehensive overviews of active shooter incidents and these incidents in healthcare facilities. They highlight response options, training considerations, and other considerations healthcare emergency planners can incorporate.
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This document provides an overview of several de-escalation frameworks and models used to measure aggression.
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In this short video, Dr. Scott Zeller demonstrates how to speak with an agitated patient to provide comfort and reassurance. He also compares the level of time and other resources needed to de-escalate versus restrain (and sedate) a patient, highlighting that many assaults could be avoided by using de-escalation techniques.
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Emergency Medical Services/Prehospital Resources


Grange, J.T., and Corbett, S.W. (2002). Violence Against Emergency Medical Services Personnel. (Abstract only.) Prehospital Emergency Care. 6(2): 186-190.
An analysis of more than 4,000 calls in one month showed that some sort of violence occurred in close to 9% of encounters, half of which was directed at prehospital care providers. The authors stress the need for training, protective gear, and protocols for dealing with violent situations.
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Kirkwood, S., and Teitsort, K. (2012). Violence Against EMS Providers: What Can We Do About It? EMSWorld.
The authors provide an overview of violence against emergency medical services providers. They stress the need for: better reporting; changes in organizational culture to make it more acceptable to report; and changes in training responders on how to protect themselves from violent individuals.
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Munding, H. (2006). Violence Against Firefighters: Angels of Mercy Under Attack. United States Fire Association.
The author conducted a literature review (and a local survey) on the nature of violence against firefighters and provides a variety of suggestions for training and standard operating procedures.
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O’Meara, P., Maguire, B., and O’Neill, B. (2019). Protecting EMS Personnel from Assault. Journal of Emergency Medical Services.
In this article, the authors share data on the prevalence of violence against EMS personnel, potential interventions, risks associated with interventions, and recommendations based on research and input from 600 paramedics from 13 countries.
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Taylor, J.A., Davis, A.L., Barnes, B., et al. (2015). Injury Risks of EMS Responders: Evidence from the National Fire Fighter Near-Miss Reporting System. BMJ Open. 5(6).
The authors reviewed 769 "non-fire emergency event" reports from the data system and categorized them. The most frequent emergency medical call was made for assaults, primarily by someone wielding a firearm.
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This white paper includes checklists and step-by-step considerations for active shooter event planning and response by pre-hospital providers, and references the framework suggested by the Hartford Consensus.
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Healthcare Settings


Beech, B., and Leather, P. (2005). Workplace Violence in the Health Care Sector: A Review of Staff Training and Integration of Training Evaluation Models. Aggression and Violent Behavior. 11(1): 27-43.
The authors discuss: workplace violence in healthcare settings, the extent of the problem, the importance of staff training, key training content, and models of training evaluation.
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Briscoe, B., Vasan, P., and Jorgensen, J. (2019). Nurses Under Attack: Violence Is Getting Worse in Hospitals.
This article shares experiences of healthcare workers in North Carolina who have been subject to violence at the hands of their patients. Photographs and video are included.
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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* Cheng, K. (2018). How to Prepare for and Survive a Violent Patient Encounter. Family Practice Management. 25(6): 5-10.
The author uses a case study to highlight contributing factors to workplace violence, lists safety and prevention tips, and discusses considerations for planning for and responding to violent patient encounters.
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Conner, D. (2018). Violence and Security in Skilled Nursing/Assisted Care Facilities. The International Association for Healthcare Security and Safety.
In this report, the author explores violence in long-term care facilities, perpetrated against other residents and staff. The author lists strategies for mitigating security challenges to prevent violence and other crimes (e.g., theft from residents and staff).
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* Coutré, L. (2019). Healthcare Workers Face Violence “Epidemic”. Modern Healthcare.
The author describes findings from interviews with healthcare executives from Ohio who referred to healthcare workplace violence as an “epidemic” and describe confiscating high numbers of weapons from patients and visitors in recent years. Those systems were considering metal detectors, de-escalation training, and apps for personnel to use to notify others they are safe or in dangerous situations.
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Critical Incident Response Group, National Center for the Analysis of Violent Crime. (2002). Workplace Violence: Issues in Response. U.S. Department of Justice, Federal Bureau of Investigation.
This report highlights findings from a “Violence in the Workplace” symposium which featured representatives from law enforcement, private industry, government, law, labor, professional organizations, victim services, the military, academia, mental health, and others.
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This review of survey results from 954 home care aides who reported verbal abuse in the past year found that they were also 11 times more likely to also report physical abuse. The author emphasizes the need for more consistent legislation and policies to recruit, retain, and ensure the safety of healthcare workers in the future.
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Gillespie, G.L., Gates, D.M., Kowalenko, T., et al. (2014). Implementation of a Comprehensive Intervention to Reduce Physical Assaults and Threats in the Emergency Department. (Abstract only.) Journal of Emergency Nursing. 40(6): 586-591.
The authors measured the effectiveness of a workplace violence reduction program against emergency department workers. While their original hypothesis was not supported, two intervention sites did see significant decreases in violence.
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Gomaa, A., Tapp, L., Luckhaupt, S. et al. (2015). Occupational Traumatic Injuries Among Workers in Health Care Facilities — United States, 2012–2014. Morbidity and Mortality Weekly Report (MMWR).
This article examines occupational injuries in the health care sector including those injuries resulting from workplace violence.
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The author discusses safety and security specific to walk‐in/public areas, emergency medical system entry points, forensic patients, general emergency department care areas, and patients with behavioral health issues.
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Violence in healthcare facilities presents a growing and significant challenge to patients, providers, support staff, and visitors. Hospital emergency departments (EDs)—where doors are always “open”—are frequently the site of violence, which is either carried over from external conflict or perpetrated by patients (and/or their loved ones) against healthcare workers. This article highlights variables that contribute to challenging situations and strategies hospitals can use to prevent them, keeping patients and staff as safe as possible.
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Judy, K., and Veselik, J. (2009). Workplace Violence: A Survey of Paediatric Residents. Occupational Medicine. 59(7): 472-475.
The authors surveyed 25 U.S. pediatric residency program directors to determine the prevalence of workplace violence in pediatric residency training programs.
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Karlsson, N., Markkanen, P., Kriebel, D., et al. (2019). Home Care Aides' Experiences of Verbal Abuse: A Survey of Characteristics and Risk Factors. Occupational and Environmental Medicine. 76(7): 448-454.
The authors reviewed survey data from 954 home healthcare aids and found that risk factors for verbal abuse include working with clients with dementia and working in homes with limited physical space. They also found that those who reported verbal abuse were 11 times as likely to report physical abuse.
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Kelen, G.D., Catlett, C.L., Kubit, J.G., and Hsieh, Y.H. (2012). Hospital-Based Shootings in the United States: 2000 to 2011. (Abstract only.) Annals of Emergency Medicine. 60(6):790-798.
The authors analyzed reports on acute care hospital shooting events in the U.S. from 2000-2011 and found 154 incidents in 40 states, resulting in 235 injured or dead victims. They provide additional demographic data (e.g., perpetrator characteristics, location of shooting).
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Kowalenko, T., Cunningham, R., Sachs, C.J., et al. (2012). Workplace Violence in Emergency Medicine: Current Knowledge and Future Directions. (Abstract only.) Journal of Emergency Medicine. 43(3):523-31.
The authors reviewed literature on emergency department workplace violence and found that staff face higher risk of physical assaults compared to other health settings. They offer suggestions for preventing and reducing violent incidents.
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Kumari, A., Kaur, T., Ranjan, P., et al. (2020). Workplace Violence Against Doctors: Characteristics, Risk Factors, and Mitigation Strategies. Journal of Postgraduate Medicine. 66(3): 149-154.
The authors reviewed literature between 2000 and 2019 that covered healthcare violence across the world. They created a classification scheme that ranked violence according to severity; examined risk factors, the issue of under-reporting, and the impact of workplace violence on staff; and reviewed interventions and areas to focus on when developing mitigation strategies.
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Larkin, H. (2021). Navigating Attacks Against Health Care Workers in the COVID-19 Era. Journal of the American Medical Association. 325(18): 1822-1824.
The author examines potential reasons behind the increase in violence against healthcare workers during the pandemic, including staffing shortages, visitor restrictions, and “changes in their patient population.” The author also reiterates the importance of reporting and the potential for technology to be used to help prevent healthcare violence.
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This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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This issue of Trajectories focuses on workplace violence in healthcare settings. The authors describe findings from a fall 2017 listening tour with Missouri Hospital Association groups who noted their top threats and themes for future consideration. The rest of the issue covers regulatory and programmatic topics, statistics related to the role of security in a healthcare facility, mitigation tools, and promoting a culture of safety.
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Morken, T., Johansen, I. and Alsaker, K. (2015). Dealing with Workplace Violence in Emergency Primary Health Care: A Focus Group Study. BMC Family Practice. 16:51.
This study explores how emergency primary health care organization personnel have dealt with threats and violence in the workplace.
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The authors provide active shooter planning guidance under five main categories: Pre-Incident Prevention and Preparation, Management During and Incident, Post Event Management, Safety Tips for Personnel and Additional Resources.
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Nachreiner, N., Gerberich, S., Ryan, A. (2007). Minnesota Nurses' Study: Perceptions of Violence and the Work Environment. (Abstract only.) Industrial Health. 45:672-678.
This study identified rates of violence against nurses in the State of Minnesota, and their perceptions of the work environment.
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* Newton, E. (n.d.). Hospital Violence Active Shooter. (Accessed 10/22/2021.)
This speaker defines active shooter incidents, illustrates the problem with recent data, outlines the planning process for hospitals, and shares information related to active shooter exercises—general and specific to her healthcare organization. (Copy and paste this link into your browser to access the PPT presentation: http://www.wsha.org/wp-content/uploads/Disaster-Readiness-5-27-Active-Shooter-Eileen-Newton.pptx)
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Occupational Safety and Health Administration. (n.d.). Pharmacy: Workplace Violence. (Accessed 10/27/2021.)
This webpage lists risk factors associated with violence in pharmacies and strategies for prevention and response.
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Occupational Safety and Health Administration. (n.d.). Workplace Violence Prevention - Health Care and Social Service Workers. (Accessed 10/22/2021.) U.S. Department of Labor.
This presentation provides an overview of the Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers published by the Occupational Safety and Health Administration (“OSHA 3148”). (Note: topics are listed alphabetically; users must scroll down to access workplace violence resources.)
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Papa, A. and Venella, J. (2013). Workplace Violence in Healthcare: Strategies for Advocacy. The Online Journal of Issues in Nursing 18(1): Manuscript 5.
This article provides a brief overview of workplace violence, and discusses the settings where it often occurs. The authors examine the direct and indirect financial impact of workplace violence (e.g., jury awards for injuries; staff turnover rates, and increased requests for medical leaves) and suggest legislative advocacy, workplace policy, and education strategies for countering violence in the workplace.
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Peek-Asa, C., Casteel, C., Veerasathpurush, A., et al. (2007). Workplace Violence and Prevention in New Jersey Hospital Emergency Departments. (Abstract only.) Journal of Occupational and Environmental Medicine. 49: 756-763.
This report highlights workplace violence prevention programs in 50 emergency departments in New Jersey hospitals. The authors identified several challenges, including uncoordinated surveillance of workplace violence events and unsatisfactory interactions between nursing staff and security personnel.
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Pompeii, L., Benavides, E., Pop, O., et al. (2020). Workplace Violence in Outpatient Physician Clinics: A Systematic Review. (Abstract only.) International Journal of Environmental Research and Public Health. 17(18): 6587.
The authors reviewed the literature on workplace violence in outpatient clinics and found the most common type of abuse was verbal, followed by threat of assault, bullying, physical assault, and sexual harassment/assault.
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This article provides an overview of workplace violence, highlights risk factors that contribute to healthcare workplace violence, and summarizes related legislation and policies. It also highlights strategies and guidance healthcare staff and security partners can incorporate into their coordinated healthcare workplace violence plans.
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Stene, J., Larson, E., Levy, M., et al. (2015). Workplace Violence in the Emergency Department: Giving Staff the Tools and Support to Report. The Permanente Journal. 19(2).
This research study examines the results of a workgroup that developed a workplace violence survey and reporting tool.
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Stephens, W. (2019). Violence Against Healthcare Workers: A Rising Epidemic. The American Journal of Managed Care.
The author describes the issue and explains that it is often unreported by healthcare workers. The causes, frequency, and effect of verbal and physical violence are also discussed, followed by strategies for evaluating high-risk patients and reducing workplace violence.
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The objective of the study was to investigate the types of workplace health and safety issues rural community nurses encounter and the impact these issues have on providing care to rural consumers.
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The Joint Commission. (2018). Physical and Verbal Violence Against Healthcare Workers. Sentinel Event Alert, Issue 59.
The Joint Commission defines what types of violent incidents constitute “sentinel events,” provides an overview of prevalence of healthcare workplace violence, lists “contributing factors” (e.g., long wait times, gang activity, and understaffing), and lists seven actions that healthcare organizations should address in their workplace violence prevention plans.
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Trotto, S. (2014). Workplace Violence in Health Care. Safety and Health Magazine.
The author discusses workplace violence in healthcare settings and provides an overview of proposed legislation to protect healthcare workers.
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* U.S. Department of Health and Human Services; U.S. Department of Homeland Security; U.S. Department of Justice, Federal Bureau of Investigation; and Federal Emergency Management Agency. (2014). Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans.
This document gives healthcare facility emergency planners, executive leadership, and others involved in emergency operations planning assistance with planning for active shooter incidents.
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This brief action guide highlights potential warning signs and response and mitigation strategies specific to an active shooter situation in a healthcare facility.
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The Occupational Safety and Health Administration lists violence prevention guidelines for the following healthcare settings: hospitals, residential and non-residential treatment, community care, and field work. The authors of the report also list the five “building blocks” for developing an effective prevention program: management commitment and employee participation; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation.
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Washington Industrial Safety and Health Act Regional Directive. (2006). Workplace Violence Prevention in Health Care. Department of Labor and Industries, Division of Occupational Safety and Health.
This policy directive was developed as a result of legislation mandating violence prevention in Washington State hospitals. Guidance is provided in a question and answer format.
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Hostage Situations


This checklist is designed to help healthcare facilities in the decision-making process during an active shooter scenario. It also addresses hostage situations throughout the document.
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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Louisiana Hospital Association. (n.d.). Sample Policy: Code Silver, Individual with a Weapon or Hostage Situation. (Accessed 10/22/2021.)
This document identifies the policies and procedures a hospital should follow during a hostage situation or an incident where an individual is wielding/ firing a weapon.
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The Center for HICS Education and Training. (n.d.). Incident Planning Guide: Hostage or Barricade Incident. (Accessed 10/22/2021.)
This guide introduces a scenario associated with a hospital hostage situation, and includes checklists for hospital and emergency management program staff to consider when addressing this type of incident.
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The Center for HICS Education and Training. (n.d.). Incident Response Guide: Hostage or Barricade Incident.
This guide provides checklists of tasks that should be completed by hospital staff during a hostage or barricade incident in the hospital. It includes checklists for the various response timeframes: immediate response (0-2 hours), intermediate response (2-12 hours), extended response (greater than 12 hours), and demobilization/ system recovery.
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American Nurses Association. (2021). Workplace Violence.
This document explains that while many states have established penalties for assaulting healthcare workers, some only apply to certain settings or types of healthcare workers. At the time the document was published, only a small subset of states across the U.S. had enacted legislation requiring employers to develop formal programs to prevent and/or report workplace violence in healthcare facilities. Most of those states require the program to be based on a risk assessment, and for staff to receive training on the workplace violence prevention plan/program. State requirements vary widely, and the laws do not include the same level of specificity and detail against which compliance may be assessed.
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Gonzalez, G. and Childers, A. (2019). States Lead the Way on Mitigating Workplace Violence in Health Care Settings. Business Insurance.
This article describes how certain states are addressing healthcare workplace violence and emphasizes the need for a federal standard. Where specific standards for workplace hazards are lacking, the Occupational Safety and Health Act’s General Duty Clause is often used to cite employers for violations.
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* The Joint Commission. (2021). Workplace Violence Prevention Compendium.
The Joint Commission recently published this compendium which includes links to resources (authored by federal agencies and medical organizations) designed to help healthcare organizations create/update related policies and programs to ensure they are in compliance with the Commission’s new workplace violence requirements (which all accredited hospitals and critical access hospitals must comply with) to be enacted in 2022.
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This Act was passed by the House of Representatives in April 2021 and referred to the Senate Committee on Health, Education, Labor, and Pensions, where it awaits additional action. If enacted, H.R. 1195 will require the U.S. Department of Labor to promulgate an occupational safety and health standard that requires covered entities to “develop and implement a comprehensive workplace violence prevention plan and carry out other activities or requirements…to protect health care workers, social service workers, and other personnel from workplace violence.”
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Plans, Tools, and Templates


American Organization of Nurse Executives and the Emergency Nurses Association. (n.d.). Toolkit for Mitigating Violence in the Workplace. (Accessed 10/22/2021.)
This toolkit highlights five focus areas of a successful workplace violence prevention program and includes links to helpful resources for nurse leaders. These resources define workplace violence and demonstrate how to create prevention plans, train and deploy staff, and evaluate progress and incorporate lessons learned from exercises and incidents.
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This white paper provides supporting documentation and other information for healthcare security professionals to create and sustain a violence prevention program.
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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This webpage includes resources that can help an emergency department manager or designated team leader develop and implement a comprehensive plan that addresses needs related to managing violent behaviors in the emergency department and protecting staff.
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Ingersoll Rand Security Technologies. (n.d.). Healthcare Security & Safety Assessment. (Accessed 10/22/2021.)
This tool was created to help healthcare facilities augment hazard vulnerability assessments, develop an understanding of their security gaps, and create strategies for improving preparedness.
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The Healthcare in Danger team from the International Committee of the Red Cross published this checklist of recommendations (and links to related resources) for preventing and responding to violence against healthcare.
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* Kerr, K.M. (2010). Workplace Violence: Planning for Prevention and Response. (Abstract only. Book and individual chapters available for purchase.) ScienceDirect ISBN: 978-1-85617-698-9.
The author provides a comprehensive overview of workplace violence, including chapters on how incidents affect victims, witnesses, the workforce, family members, and management. Additional chapters can help organizations to form action and response plans to manage incidents of any size.
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* Minnesota Department of Labor and Industry. (n.d.). Workplace Safety Consultation -- Workplace Violence Prevention. (Accessed 10/22/2021.)
The Minnesota Department of Labor and Industry has established a Workplace Violence Prevention Resource Center to assist the public by offering a resource library, plan templates, and other resources to assist with implementing a workplace violence prevention program.
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Minnesota Hospital Association. (2019). Health Care and Law Enforcement Collaboration Roadmap.
This resource stresses the benefit of interdisciplinary safety teams and communications and security plans. Laid out like a checklist, it includes links to related resources that can help healthcare facilities create and follow their own maps.
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NJHA Emergency Management. (2018). Security Readiness Assessment Tool.
This tool can be used by healthcare facility security staff to develop or update existing security plans. It was updated in 2018 and includes general guidance for three types of facilities: acute care, long-term care, and Federally Qualified Health Centers.
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NYC Health & Hospitals and Jacobi. (n.d.). Violence Reduction Protocol Treatment Plan. (Accessed 10/28/2021.)
Healthcare providers can use this set of forms and guidance to document patient behavior and develop plans to help manage care and prevent violent behavior.
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Occupational Safety and Health Administration. (2002). Workplace Violence Fact Sheet. U.S. Department of Labor.
This fact sheet identifies workplace violence, describes actions that employers and employees can take to protect themselves, and lists additional resources.
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* Occupational Safety and Health Administration. (2015). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. U.S. Department of Labor.
This document is an update of the Occupational Safety and Health Administration’s 1996 and 2004 voluntary guidelines for preventing workplace violence for healthcare and social service workers.
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* U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Active Shooter Planning and Response in a Healthcare Setting.
This document provides active shooter guidance tailored specifically to the healthcare setting.
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U.S. Department of Labor. (n.d.). Department of Labor Workplace Violence Program. (Accessed 10/22/2021.)
This document comprehensively describes the Department of Labor’s Workplace Violence Program including policies and procedures, identification, prevention and response.
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The Occupational Safety and Health Administration lists violence prevention guidelines for the following healthcare settings: hospitals, residential and non-residential treatment, community care, and field work. The authors of the report also list the five “building blocks” for developing an effective prevention program: management commitment and employee participation; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation.
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This white paper includes checklists and step-by-step considerations for active shooter event planning and response by pre-hospital providers, and references the framework suggested by the Hartford Consensus.
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Washington State Legislature. (2000). Workplace Safety Plan.
This policy statement mandates that Washington State psychiatric hospitals develop a plan to “reasonably prevent and protect employees from violence at the state hospital.” The statement includes plan components, such as staffing/security staffing, first aid procedures, reporting, and education and training.
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Prevention Resources


Anderson, A., and West, S. (2011). Violence Against Mental Health Professionals: When the Treater Becomes the Victim. Innovations in Clinical Neuroscience. 8(3).
The authors examine several studies regarding workplace violence in the mental health setting (e.g., what precipitates it, populations more likely to become violent) and discuss possible methods of preventing violence.
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The author lists and fleshes out the following six steps for hospital executives to take to minimize healthcare workplace violence: know your jurisdiction, set policies and protocols, mandate assault reporting, investigate violent incidents, enforce policies, and press charges.
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* Cheng, K. (2018). How to Prepare for and Survive a Violent Patient Encounter. Family Practice Management. 25(6): 5-10.
The author uses a case study to highlight contributing factors to workplace violence, lists safety and prevention tips, and discusses considerations for planning for and responding to violent patient encounters.
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This webpage and presentation highlight violence prevention strategies taught by the Crisis Prevention Institute.
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Division of Workers’ Compensation and Workplace Safety. (n.d.). Health Care Facilities and Workplace Violence Prevention. (Accessed 10/22/2021.) Texas Department of Insurance.
This brochure can increase healthcare facility employee and employer awareness of the risk factors for violence in these settings. The brochure also includes strategies for reducing exposure to risks.
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Gross, N., Peek-Asa, C., Nocera, M., et al. (2013). Workplace Violence Prevention Policies in Home Health and Hospice Care Agencies. The Online Journal of Issues in Nursing. 18(1): Manuscript 1.
The authors examined workplace violence prevention programs in 40 California home health and hospice agencies and discuss their findings.
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Henkel, S. (2019). Threat Assessment Strategies to Mitigate Violence in Healthcare. International Association for Healthcare Security and Safety Foundation.
The author describes the problem and the related regulatory environment and how staff who specialize in behavioral health, facility security personnel, front-line supervisors, and legal and labor union representatives can work “to create a culture of reporting in order to best detect threats.” This includes collaborative assessment of the threat and determining next steps (management and mitigation), done by level of threat (low, moderate, and high), concluding with ongoing case management.
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Hodges, M. and Arata, L. (2019). Developing a Comprehensive Workplace Violence Prevention Program. AOHP National Conference.
The speakers highlight the prevalence of workplace violence and the direct and indirect costs associated with injuries. They also emphasize the importance of training, employee engagement, and having various employee response options (e.g., threat assessment protocols).
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Violence in healthcare facilities presents a growing and significant challenge to patients, providers, support staff, and visitors. Hospital emergency departments (EDs)—where doors are always “open”—are frequently the site of violence, which is either carried over from external conflict or perpetrated by patients (and/or their loved ones) against healthcare workers. This article highlights variables that contribute to challenging situations and strategies hospitals can use to prevent them, keeping patients and staff as safe as possible.
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This guide provides important information to assist department and agency security planners as they develop and review Occupant Emergency Programs for the safety and security of employees and visitors at non-military Federal facilities. To further support security specialists in this effort, this guide outlines the components of an effective Occupant Emergency Program, including those items that comprise an emergency plan.
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This ISC Guide aims to provide guidance for organizations in formulating and ultimately implementing an operable and effective Facility Security Plan (FSP). A Facility Security Plan is a critical component of an effective security program and of a complete EOP. The guidelines contained in this document are based on recognized industry best practices and provide broad recommendations for the protection of Federal facilities and Federal employees, contractors, and visitors within them.
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The Healthcare in Danger team from the International Committee of the Red Cross published this checklist of recommendations (and links to related resources) for preventing and responding to violence against healthcare.
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* Kerr, K.M. (2010). Workplace Violence: Planning for Prevention and Response. (Abstract only. Book and individual chapters available for purchase.) ScienceDirect ISBN: 978-1-85617-698-9.
The author provides a comprehensive overview of workplace violence, including chapters on how incidents affect victims, witnesses, the workforce, family members, and management. Additional chapters can help organizations to form action and response plans to manage incidents of any size.
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McPhaul, K., London, M., and Lipscomb, J. (2013). A Framework for Translating Workplace Violence Intervention Research into Evidence-Based Programs. The Online Journal of Issues in Nursing. 18(1): Manuscript 4.
This article provides background information about workplace violence and offers a framework for developing comprehensive workplace violence prevention programs built on the existing scientific evidence and regulatory guidance.
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* Minnesota Department of Labor and Industry. (n.d.). Workplace Safety Consultation -- Workplace Violence Prevention. (Accessed 10/22/2021.)
The Minnesota Department of Labor and Industry has established a Workplace Violence Prevention Resource Center to assist the public by offering a resource library, plan templates, and other resources to assist with implementing a workplace violence prevention program.
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Morken, T., and Johansen, I. (2013). Safety Measures to Prevent Workplace Violence in Emergency Primary Care Centres--a Cross-Sectional Study. BMC Health Services Research. 13:384.
The authors investigated the extent to which general practitioners work alone in emergency primary care centers in Norway, and estimated the prevalence of preventive measures against workplace violence.
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National Institute for Occupational Safety and Health. (2004). Workplace Violence Prevention Strategies and Research Needs. Centers for Disease Control and Prevention.
These conference proceedings are categorized into three categories: 1) overcoming current barriers and gaps that impede collaborative research, prevention, and communication work; 2) characteristics of effective workplace violence prevention programs; and 3) research and partnerships needed to further advance prevention.
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Occupational Safety and Health Administration. (n.d.). Workplace Violence Prevention Programs. (Accessed 10/22/2021.) U.S. Department of Labor.
This webpage of references provides guidance for preventing violence in the workplace. References are grouped into three categories: Occupational Health and Safety Administration Guidance, Other Federal Agency Guidance, and State and Local Guidance.
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* Occupational Safety and Health Administration. (2015). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. U.S. Department of Labor.
This document is an update of the Occupational Safety and Health Administration’s 1996 and 2004 voluntary guidelines for preventing workplace violence for healthcare and social service workers.
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Occupational Safety and Health Administration. (2015). Workplace Violence. U.S. Department of Labor.
This website provides information on the extent of violence in the workplace, assessing the hazards in different settings and developing workplace violence prevention plans for individual worksites.
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This article provides an overview of workplace violence, highlights risk factors that contribute to healthcare workplace violence, and summarizes related legislation and policies. It also highlights strategies and guidance healthcare staff and security partners can incorporate into their coordinated healthcare workplace violence plans.
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* The Joint Commission. (2021). Workplace Violence Prevention Compendium.
The Joint Commission recently published this compendium which includes links to resources (authored by federal agencies and medical organizations) designed to help healthcare organizations create/update related policies and programs to ensure they are in compliance with the Commission’s new workplace violence requirements (which all accredited hospitals and critical access hospitals must comply with) to be enacted in 2022.
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This webpage includes links to workplace violence presentations and other materials shared by presenters from five healthcare organizations. These resources highlight lessons learned from real experiences and sample policies.
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U.S. Department of Agriculture. (2015). Workplace Violence Prevention.
This webpage provides access to the U.S. Department of Agriculture policies and procedures to address and prevent workplace violence. It also includes informational reports, national hotline resources, and information on reporting situations of imminent danger.
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The Occupational Safety and Health Administration lists violence prevention guidelines for the following healthcare settings: hospitals, residential and non-residential treatment, community care, and field work. The authors of the report also list the five “building blocks” for developing an effective prevention program: management commitment and employee participation; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation.
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Statistics and Data


Bureau of Labor Statistics. (2014). Census of Fatal Occupational Injuries-Archived Data. U.S. Department of Labor.
This webpage has links to tables, charts, reports, issue papers and articles in TXT or PDF formats for data on fatal occupational injuries. Data for “Assaults and Violent Acts” are included.
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* Coutré, L. (2019). Healthcare Workers Face Violence “Epidemic”. Modern Healthcare.
The author describes findings from interviews with healthcare executives from Ohio who referred to healthcare workplace violence as an “epidemic” and describe confiscating high numbers of weapons from patients and visitors in recent years. Those systems were considering metal detectors, de-escalation training, and apps for personnel to use to notify others they are safe or in dangerous situations.
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* Gao, H. and Adashi, E. (2015). An Analysis of Active Shooters in the Hospital Setting, 2000-2015. Alpert School of Medicine at Brown University.
This infographic illustrates the frequency of active shooter incidents and lists location demographics and motive and disposition of perpetrators. The authors found that more shootings are happening inside of healthcare facilities, the most common motive is a “grudge,” and incidents are often perpetrated by inmates trying to escape.
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Groenwold, M., Sarmiento, R., Vanoli, K., et al. (2017). Workplace Violence Injury in 106 U.S. Hospitals Participating in the Occupational Health Safety Network (OHSN), 2012-2015. (Abstract only.) American Journal of Industrial Medicine.
This study of violent incidents tracked in 106 hospitals between 2012 and 2015 found that nursing assistants and nurses and nursing assistants had the highest injury rate per 1,000 full-time equivalent employees.
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Kansagra, S. M., Rao, S. R., Sullivan, A. F., et al. (2008). A Survey of Workplace Violence Across 65 U.S. Emergency Departments. Academic Emergency Medicine. 15 (12):1268–1274.
This study examines emergency department workplace violence and staff perceptions of physical safety.
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Kowalenko, T., Hauff, S., Morden, P. et al. (2012). Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers. Western Journal of Medicine 13(5):429-33.
The authors highlight the development process and evaluation of an instrument created to collect data relevant to violence against healthcare workers.
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Omar, H., Yue, R., Amen, A., et al. (2018). Reassessment of Violence Against Emergency Physicians. Annals of Emergency Medicine. 72(4S).
The authors compared the results of two surveys to determine how rates of violence against emergency physicians have changed between 2005 and 2018. Nearly 80% of respondents had been threatened by a patient and 71% had witnessed others being assaulted.
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The author reviews literature specific to workplace violence and summarizes anecdotal evidence on how it has increased during the COVID-19 pandemic.
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U.S. Bureau of Labor Statistics. (2020). Fact Sheet. Workplace Violence in Healthcare, 2018.
Charts and tables illustrate the incidence of nonfatal workplace violence to healthcare workers, injuries and illnesses with days away from work, and incidence by healthcare industry.
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U.S. Fire Adminstration. (2017). Mitigation of Occupational Violence to Firefighters and EMS Responders. Federal Emergency Management Agency.
The authors reviewed the literature on violence against firefighters and emergency medical systems responders and categorized it under nine themes: historical and contextual grounding, evolution of the definition of violence, characteristics of patients/perpetrators of violence, estimates of violence, EMS responder risk factors, psychosocial impact, under-reporting, best practices, and inventory of best practices and intervention opportunities.
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Federal Bureau of Investigation. Active Shooter Incidents.
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U.S. Department of Homeland Security. Active Shooter Preparedness.
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U.S. Department of Homeland Security. First Responder.
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