US DOL OSHA Guidelines

Workplace Violence -- A Special Seminar

Seminar Library

This is one of several U.S. Dept. of Labor OSHA documents.
See http://spider/osha.gov/oshpubs/workplace

Guidelines for Preventing Workplace Violence for  Social Service Workers-OSHA 3148-1996

 

Introduction

For many years, health care and social service workers have faced a significant

risk of job-related violence. Assaults represent a serious safety and health

hazard for these industries, and violence against their employees continues to

increase. 


OSHA's new violence prevention guidelines provide the agency's recommendations

for reducing workplace violence developed following a careful review of

workplace violence studies, public and private violence prevention programs, and

consultations with and input from stakeholders. 



OSHA encourages employers to establish violence prevention programs and to track

their progress in reducing work-related assaults. Although not every incident

can be prevented, many can, and the severity of injuries sustained by employees

reduced.

OSHA's Commitment

The publication and distribution of these guidelines is OSHA's first step in

assisting health care and social service employers and providers in preventing

workplace violence. OSHA plans to conduct a coordinated effort consisting of

research, information, training, cooperative programs, and appropriate

enforcement to accomplish this goal. 


The guidelines are not a new standard or regulation. They are advisory in

nature, informational in content, and intended for use by employers in providing

a safe and healthful workplace through effective violence prevention programs,

adapted to the needs and resources of each place of employment. 



Extent of Problem

Today, more assaults occur in the health care and social services industries

than in any other. For example, Bureau of Labor Statistics (BLS) data for 1993

showed health care and social service workers having the highest incidence of

assault injuries (BLS, 1993). Almost two-thirds of the nonfatal assaults

occurred in nursing homes, hospitals, and establishments providing residential

care and other social services (Toscano and Weber, 1995). 


Assaults against workers in the health professions are not new. According to one

study (Goodman et al., 1994), between 1980 and 1990, 106 occupational

violence-related deaths occurred among the following health care workers: 27

pharmacists, 26 physicians, 18 registered nurses, 17 nurses' aides, and 18

health care workers in other occupational categories. Using the National

Traumatic Occupational Fatality database, the study reported that between 1983

and 1989, there were 69 registered nurses killed at work. Homicide was the

leading cause of traumatic occupational death among employees in nursing homes

and personal care facilities. 


A 1989 report (Carmel and Hunter) found that the nursing staff at a psychiatric

hospital sustained 16 assaults per 100 employees per year. This rate, which

includes any assault-related injuries, compares with 8.3 injuries of all types

per 100 full-time workers in all industries and 14.2 per 100 full-time workers

in the construction industry (BLS, 1991). Of 121 psychiatric hospital workers

sustaining 134 injuries, 43 percent involved lost time from work with 13 percent

of those injured missing more than 21 days from work. 


Of greater concern is the likely underreporting of violence and a persistent

perception within the health care industry that assaults are part of the job.

Underreporting may reflect a lack of institutional reporting policies, employee

beliefs that reporting will not benefit them, or employee fears that employers

may deem assaults the result of employee negligence or poor job performance. 



Risk Factors

Health care and social service workers face an increased risk of work-related
assaults stemming from several factors, including:
£ The prevalence of handguns and other weapons as high as 25 percent5 among
patients, their families, or friends. The increasing use of hospitals by police
and the criminal justice systems for criminal holds and the care of acutely
disturbed, violent individuals.
£ The increasing number of acute and chronically mentally ill patients now being
released from hospitals without followup care, who now have the right to refuse
medicine and who can no longer be hospitalized involuntarily unless they pose an
immediate threat to themselves or others.
£ The availability of drugs or money at hospitals, clinics, and pharmacies,
making them likely robbery targets.
£ Situational and circumstantial factors such as unrestricted movement of the
public in clinics and hospitals; the increasing presence of gang members, drug
or alcohol abusers, trauma patients, or distraught family members; long waits in
emergency or clinic are also leading to client frustration over an inability to
obtain needed services promptly.
£ Low staffing levels during times of specific increased activity such as meal
times, visiting times, and when staff are transporting patients. 
£ Isolated work with clients during examinations or treatment. 
£ Solo work, often in remote locations, particularly in high-crime settings,
with no back-up or means of obtaining assistance such as communication devices
or alarm systems.

£ Lack of training of staff in recognizing and managing escalating hostile and
assaultive behavior.
£ Poorly lighted parking areas.



Overview of Guidelines

In January 1989, OSHA published voluntary, generic safety and health program

management guidelines for all employers to use as a foundation for their safety

and health programs, which can include a workplace violence prevention program.6

OSHA's violence prevention guidelines build on the 1989 generic guidelines by

identifying common risk factors and describing some feasible solutions. Although

not exhaustive, the new workplace violence guidelines include policy

recommendations and practical corrective methods to help prevent and mitigate

the effects of workplace violence. 



The goal is to eliminate or reduce worker exposure to conditions that lead to

death or injury from violence by implementing effective security devices and

administrative work practices, among other control measures. 



The guidelines cover a broad spectrum of workers who provide health care and

social services in psychiatric facilities, hospital emergency departments,

community mental health clinics, drug abuse treatment clinics, pharmacies,

community care facilities, and long-term care facilities. They include

physicians, registered nurses, pharmacists, nurse practitioners, physicians'

assistants, nurses' aides, therapists, technicians, public health nurses, home

health care workers, social/welfare workers, and emergency medical care

personnel. Further, the guidelines may be useful in reducing risks for ancillary

personnel such as maintenance, dietary, clerical, and security staff employed in

the health care and social services industries.

Violence Prevention Program Element
There are four main components to any effective safety and health program that

also apply to preventing workplace violence, (1) management commitment and

employee involvement, (2) worksite analysis, (3) hazard prevention and control,

and (4) safety and health training. 


Management Commitment and Employee Involvement 

Management commitment and employee involvement are complementary and essential

elements of an effective safety and health program. To ensure an effective

program, management and front-line employees must work together, perhaps through

a team or committee approach. If employers opt for this strategy, they must be

careful to comply with the applicable provisions of the National Labor Relations

Act. 

Management commitment, including the endorsement and visible involvement of top

management, provides the motivation and resources to deal effectively with

workplace violence, and should include the following: 

£ Demonstrated organizational concern for employee emotional and physical safety
  and health. 
£ Equal commitment to worker safety and health and patient/client safety. 
£ Assigned responsibility for the various aspects of the workplace violence
  prevention program to ensure that all managers, supervisors, and employees
  understand their obligations. 
£ Appropriate allocation of authority and resources to all responsible parties.
£ A system of accountability for involved managers, supervisors, and employees. 
£ A comprehensive program of medical and psychological counseling and debriefing
  for employees experiencing or witnessing assaults and other violent incidents. 
£ Commitment to support and implement appropriate recommendations from safety
  and health committees. 

Employee involvement and feedback enable workers to develop and express their

own commitment to safety and health and provide useful information to design,

implement, and evaluate the program. 

Employee involvement should include the following: 

* Understanding and complying with the workplace violence prevention program and
other safety and security measures. 
* Participation in an employee complaint or suggestion procedure covering safety
and security concerns. 
* Prompt and accurate reporting of violent incidents. 
* Participation on safety and health committees or teams that receive reports of
violent incidents or security problems, make facility inspections, and respond
with recommendations for corrective strategies. 
* Taking part in a continuing education program that covers techniques to
recognize escalating agitation, assaultive behavior, or criminal intent, and
discusses appropriate responses. 



Written Program

A written program for job safety and security, incorporated into the

organization's overall safety and health program, offers an effective approach

for larger organizations. In smaller establishments, the program need not be

written or heavily documented to be satisfactory. What is needed are clear goals

and objectives to prevent workplace violence suitable for the size and

complexity of the workplace operation and adaptable to specific situations in

each establishment. 



The prevention program and startup date must be communicated to all employees.

At a minimum, workplace violence prevention programs should do the following: 

£ Create and disseminate a clear policy of zero-tolerance for workplace
  violence, verbal and nonverbal threats, and related actions. Managers,
  supervisors, co-workers, clients, patients, and visitors must be advised of this
  policy. 
£ Ensure that no reprisals are taken against an employee who reports or
  experiences workplace violence . 
£ Encourage employees to promptly report incidents and to suggest ways to reduce
  or eliminate risks. Require records of incidents to assess risk. 
£ Outline a comprehensive plan for maintaining security in the workplace, which
  includes establishing a liaison with law enforcement representatives and others
  who can help identify ways to prevent and mitigate workplace violence. 
£ Assign responsibility and authority for the program to individuals or teams
  with appropriate training and skills. The written plan should ensure that there
  are adequate resources available for this effort and that the team or

  responsible individuals develop expertise on workplace violence prevention in
  health care and social services. 
£ Affirm management commitment to a worker-supportive environment that places as
  much importance on employee safety and health as on serving the patient or
  client. 
£ Set up a company briefing as part of the initial effort to address such issues
  as preserving safety, supporting affected employees, and facilitating recovery. 

Worksite Analysis

Worksite analysis involves a step-by-step, common-sense look at the workplace to

find existing or potential hazards for workplace violence. This entails

reviewing specific procedures or operations that contribute to hazards and

specific locales where hazards may develop. 


A "Threat Assessment Team," "Patient Assault Team," similar task force, or

coordinator may assess the vulnerability to workplace violence and determine the

appropriate preventive actions to be taken. Implementing the workplace violence

prevention program then may be assigned to this group. The team should include

representatives from senior management, operations, employee assistance,

security, occupational safety and health, legal, and human resources staff. 


The team or coordinator can review injury and illness records and workers'

compensation claims to identify patterns of assaults that could be prevented by

workplace adaptation, procedural changes, or employee training. As the team or

coordinator identifies appropriate controls, these should be instituted. 


The recommended program for worksite analysis includes, but is not limited to,

analyzing and tracking records, monitoring trends and analyzing incidents,

screening surveys, and analyzing workplace security. 



Records Analysis and Tracking

This activity should include reviewing medical, safety, workers' compensation

and insurance records including the OSHA 200 log, if required to pinpoint

instances of workplace violence. Scan unit logs and employee and police reports

of incidents or near-incidents of assaultive behavior to identify and analyze

trends in assaults relative to particular departments, units, job titles, unit

activities, work stations, and/or time of day. Tabulate these data to target the

frequency and severity of incidents to establish a baseline for measuring

improvement. 



Monitoring Trends and Analyzing Incidents 

Contacting similar local businesses, trade associations, and community and civic

groups is one way to learn about their experiences with workplace violence and

to help identify trends. Use several years of data, if possible, to trace trends

of injuries and incidents of actual or potential workplace violence. 



Screening Surveys

One important screening tool is to give employees a questionnaire or survey to

get their ideas on the potential for violent incidents and to identify or

confirm the need for improved security measures. Detailed baseline screening

surveys can help pinpoint tasks that put employees at risk. Periodic surveys

conducted at least annually or whenever operations change or incidents of

workplace violence occur help identify new or previously unnoticed risk factors

and deficiencies or failures in work practices, procedures, or controls. Also,

the surveys help assess the effects of changes in the work processes (see

Appendix A for a sample survey used in the State of Washington). The periodic

review process should also include feedback and followup. 


Independent reviewers, such as safety and health professionals, law enforcement

or security specialists, insurance safety auditors, and other qualified persons

may offer advice to strengthen programs. These experts also can provide fresh

perspectives to improve a violence prevention program. 



Workplace Security Analysis

The team or coordinator should periodically inspect the workplace and evaluate

employee tasks to identify hazards, conditions, operations, and situations that

could lead to violence. 

To find areas requiring further evaluation, the team or coordinator should do

the following: 

* Analyze incidents, including the characteristics of assailants and victims, an
  account of what happened before and during the incident, and the relevant
  details of the situation and its outcome. When possible, obtain police reports
  and recommendations. 
* Identify jobs or locations with the greatest risk of violence as well as
  processes and procedures that put employees at risk of assault, including how
  often and when. 
* Note high-risk factors such as types of clients or patients (e.g., psychiatric
  conditions or patients disoriented by drugs, alcohol, or stress); physical risk
  factors of the building; isolated locations/job activities; lighting problems;
  lack of phones and other communication devices, areas of easy, unsecured access;

  and areas with previous security problems. (See sample checklist for assessing
  hazards in Appendix B.) 
* Evaluate the effectiveness of existing security measures, including
  engineering control measures. Determine if risk factors have been reduced or
  eliminated, and take appropriate action.

Hazard Prevention and Control

After hazards of violence are identified through the systematic worksite

analysis, the next step is to design measures through engineering or

administrative and work practices to prevent or control these hazards. If

violence does occur, post-incidence response can be an important tool in

preventing future incidents. 



Engineering Controls and Workplace Adaptation 

Engineering controls, for example, remove the hazard from the workplace or

create a barrier between the worker and the hazard. There are several measures

that can effectively prevent or control workplace hazards, such as those actions

presented in the following paragraphs. The selection of any measure, of course,

should be based upon the hazards identified in the workplace security analysis

of each facility. 

* Assess any plans for new construction or physical changes to the facility or
  workplace to eliminate or reduce security hazards. 
* Install and regularly maintain alarm systems and other security devices, panic
  buttons, hand-held alarms or noise devices, cellular phones, and private channel
  radios where risk is apparent or may be anticipated, and arrange for a reliable
  response system when an alarm is triggered. 
* Provide metal detectors installed or hand-held, where appropriate to identify
  guns, knives, or other weapons, according to the recommendations of security
  consultants. 
* Use a closed-circuit video recording for high-risk areas on a 24-hour basis.
  Public safety is a greater concern than privacy in these situations. 
* Place curved mirrors at hallway intersections or concealed areas. 
* Enclose nurses' stations, and install deep service counters or
  bullet-resistant, shatter-proof glass in reception areas, triage, admitting, or
  client service rooms. 
* Provide employee "safe rooms" for use during emergencies. 
* Establish "time-out" or seclusion areas with high ceilings without grids for
  patients acting out and establish separate rooms for criminal patients. 
* Provide client or patient waiting rooms designed to maximize comfort and
  minimize stress. 
* Ensure that counseling or patient care rooms have two exits. 
* Limit access to staff counseling rooms and treatment rooms controlled by using
  locked doors. 
* Arrange furniture to prevent entrapment of staff. In interview rooms or crisis
  treatment areas, furniture should be minimal, lightweight, without sharp corners
  or edges, and/or affixed to the floor. Limit the number of pictures, vases,
  ashtrays, or other items that can be used as weapons. 
* Provide lockable and secure bathrooms for staff members separate from
  patient-client, and visitor facilities. 
* Lock all unused doors to limit access, in accordance with local fire codes. 
* Install bright, effective lighting indoors and outdoors. 
* Replace burned-out lights, broken windows, and locks. 
* Keep automobiles, if used in the field, well-maintained. Always lock
  automobiles. 



Administrative and Work Practice Controls 

* Administrative and work practice controls affect the way jobs or tasks are

performed. The following examples illustrate how changes in work practices and

administrative procedures can help prevent violent incidents. 

* State clearly to patients, clients, and employees that violence is not

permitted or tolerated. 

* Establish liaison with local police and state prosecutors. Report all

incidents of violence. Provide police with physical layouts of facilities to

expedite investigations. 

* Require employees to report all assaults or threats to a supervisor or manager

(e.g., can be confidential interview). Keep log books and reports of such

incidents to help in determining any necessary actions to prevent further

occurrences. 

* Advise and assist employees, if needed, of company procedures for requesting

police assistance or filing charges when assaulted. 

* Provide management support during emergencies. Respond promptly to all

complaints.

* Set up a trained response team to respond to emergencies. 

* Use properly trained security officers, when necessary, to deal with

aggressive behavior. Follow written security procedures. 

* Ensure adequate and properly trained staff for restraining patients or

clients. 

* Provide sensitive and timely information to persons waiting in line or in

waiting rooms. Adopt measures to decrease waiting time. 

* Ensure adequate and qualified staff coverage at all times. Times of greatest

risk occur during patient transfers, emergency responses, meal times, and at

night. Locales with the greatest risk include admission units and crisis or

acute care units. Other risks include admission of patients with a history of

violent behavior or gang activity. 

* Institute a sign-in procedure with passes for visitors, especially in a

newborn nursery or pediatric department. Enforce visitor hours and procedures. 

* Establish a list of "restricted visitors" for patients with a history of

violence. Copies should be available at security checkpoints, nurses' stations,

and visitor sign-in areas. Review and revise visitor check systems, when

necessary. Limit information given to outsiders on hospitalized victims of

violence. 

* Supervise the movement of psychiatric clients and patients throughout the

facility. 

* Control access to facilities other than waiting rooms, particularly drug

storage or pharmacy areas. 

* Prohibit employees from working alone in emergency areas or walk-in clinics,

particularly at night or when assistance is unavailable. Employees should never

enter seclusion rooms alone. 

* Establish policies and procedures for secured areas, and emergency

evacuations, and for monitoring high-risk patients at night (e.g., open versus

locked seclusion). 

* Ascertain the behavioral history of new and transferred patients to learn

about any past violent or assaultive behaviors. Establish a system such as chart

tags, log books, or verbal census reports to identify patients and clients with

assaultive behavior problems, keeping in mind patient confidentiality and worker

safety issues. Update as needed. 

* Treat and/or interview aggressive or agitated clients in relatively open areas

that still maintain privacy and confidentiality (e.g., rooms with removable

partitions). 

* Use case management conferences with co-workers and supervisors to discuss

ways to effectively treat potentially violent patients. 

* Prepare contingency plans to treat clients who are "acting out" or making

verbal or physical attacks or threats. Consider using certified employee

assistance professionals (CEAPs) or in-house social service or occupational

health service staff to help diffuse patient or client anger. 

* Transfer assaultive clients to "acute care units," "criminal units," or other

more restrictive settings. 

* Make sure that nurses and/or physicians are not alone when performing intimate

physical examinations of patients. 

* Discourage employees from wearing jewelry to help prevent possible

strangulation in confrontational situations. Community workers should carry only

required identification and money. 

* Periodically survey the facility to remove tools or possessions left by

visitors or maintenance staff which could be used inappropriately by patients. 

* Provide staff with identification badges, preferably without last names, to

readily verify employment. 

* Discourage employees from carrying keys, pens, or other items that could be

used as weapons. 

* Provide staff members with security escorts to parking areas in evening or

late hours. Parking areas should be highly visible, well-lighted, and safely

accessible to the building. * Use the "buddy system," especially when personal

safety may be threatened. Encourage home health care providers, social service

workers, and others to avoid threatening situations. Staff should exercise extra

care in elevators, stairwells and unfamiliar residences; immediately leave

premises if there is a hazardous situation; or request police escort if needed. 

* Develop policies and procedures covering home health care providers, such as

contracts on how visits will be conducted, the presence of others in the home

during the visits, and the refusal to provide services in a clearly hazardous

situation. 

* Establish a daily work plan for field staff to keep a designated contact

person informed about workers' whereabouts throughout the workday. If an

employee does not report in, the contact person should followup. 

* Conduct a comprehensive post-incident evaluation, including psychological as

well as medical treatment, for employees who have been subjected to abusive

behavior. 



Post-Incident Response
Post-incident response and evaluation are essential to an effective violence

prevention program. All workplace violence programs should provide comprehensive

treatment for victimized employees and employees who may be traumatized by

witnessing a workplace violence incident. Injured staff should receive prompt

treatment and psychological evaluation whenever an assault takes place,

regardless of severity. (See sample hospital policy in Appendix C).

Transportation of the injured to medical care should be provided if care is not

available on-site. 


Victims of workplace violence suffer a variety of consequences in addition to

their actual physical injuries. These include short and long-term psychological

trauma, fear of returning to work, changes in relationships with co-workers and

family, feelings of incompetence, guilt, powerlessness, and fear of criticism by

supervisors or managers. Consequently, a strong followup program for these

employees will not only help them to deal with these problems but also to help

prepare them to confront or prevent future incidents of violence (Flannery,

1991, 1993; 1995). 



There are several types of assistance that can be incorporated into the

post-incident response. For example, trauma-crisis counseling, critical incident

stress debriefing, or employee assistance programs may be provided to assist

victims. Certified employee assistance professionals, psychologists,

psychiatrists, clinical nurse specialists, or social workers could provide this

counseling, or the employer can refer staff victims to an outside specialist. In

addition, an employee counseling service, peer counseling, or support groups may

be established. 



In any case, counselors must be well trained and have a good understanding of

the issues and consequences of assaults and other aggressive, violent behavior.

Appropriate and promptly rendered post-incident debriefings and counseling

reduce acute psychological trauma and general stress levels among victims and

witnesses. In addition, such counseling educates staff about workplace violence

and positively influences workplace and organizational cultural norms to reduce

trauma associated with future incidents. 

Training and Education

Training and education ensure that all staff are aware of potential security

hazards and how to protect themselves and their co-workers through established

policies and procedures. 



All Employees

Every employee should understand the concept of "Universal Precautions for

Violence," i.e., that violence should be expected but can be avoided or

mitigated through preparation. Staff should be instructed to limit physical

interventions in workplace altercations whenever possible, unless there are

adequate numbers of staff or emergency response teams and security personnel

available. Frequent training also can improve the likelihood of avoiding assault

(Carmel and Hunter, 1990). 



Employees who may face safety and security hazards should receive formal

instruction on the specific hazards associated with the unit or job and

facility. This includes information on the types of injuries or problems

identified in the facility and the methods to control the specific hazards. 



The training program should involve all employees, including supervisors and

managers. New and reassigned employees should receive an initial orientation

prior to being assigned their job duties. Visiting staff, such as physicians,

should receive the same training as permanent staff. Qualified trainers should

instruct at the comprehension level appropriate for the staff. Effective

training programs should involve role playing, simulations, and drills. 



Topics may include Management of Assaultive Behavior; Professional Assault


Response Training; police assault avoidance programs, or personal safety

training such as awareness, avoidance, and how to prevent assaults. A

combination of training may be used depending on the severity of the risk. 



Required training should be provided to employees annually. In large

institutions, refresher programs may be needed more frequently (monthly or

quarterly) to effectively reach and inform all employees. 



The training should cover topics such as the following: 

* The workplace violence prevention policy. 

* Risk factors that cause or contribute to assaults. 

* Early recognition of escalating behavior or recognition of warning signs or

situations that may lead to assaults. 

* Ways of preventing or diffusing volatile situations or aggressive behavior,

managing anger, and appropriately using medications as chemical restraints. 

* Information on multicultural diversity to develop sensitivity to racial and

ethnic issues and differences. 

* A standard response action plan for violent situations, including availability

of assistance, response to alarm systems, and communication procedures. 

* How to deal with hostile persons other than patients and clients, such as

relatives and visitors. 

* Progressive behavior control methods and safe methods of restraint application

or escape. 

* The location and operation of safety devices such as alarm systems, along with

the required maintenance schedules and procedures. 

* Ways to protect oneself and coworkers, including use of the "buddy system." 

* Policies and procedures for reporting and recordkeeping. 

* Policies and procedures for obtaining medical care, counseling, workers'

compensation, or legal assistance after a violent episode or injury. 



Supervisors, Managers, and Security Personnel 

Supervisors and managers should ensure that employees are not placed in

assignments that compromise safety and should encourage employees to report

incidents. Employees and supervisors should be trained to behave compassionately

towards coworkers when an incident occurs. 



They should learn how to reduce security hazards and ensure that employees

receive appropriate training. Following training, supervisors and managers

should be able to recognize a potentially hazardous situation and to make any

necessary changes in the physical plant, patient care treatment program, and

staffing policy and procedures to reduce or eliminate the hazards. 



Security personnel need specific training from the hospital or clinic, including

the psychological components of handling aggressive and abusive clients, types

of disorders, and ways to handle aggression and defuse hostile situations. 



The training program should also include an evaluation. The content, methods,

and frequency of training should be reviewed and evaluated annually by the team

or coordinator responsible for implementation. Program evaluation may involve

supervisor and/or employee interviews, testing and observing, and/or reviewing

reports of behavior of individuals in threatening situations. 

Recordkeeping and Evaluation of the Program 

Recordkeeping and evaluation of the violence prevention program are necessary to

determine overall effectiveness and identify any deficiencies or changes that

should be made. 



Recordkeeping

Recordkeeping is essential to the success of a workplace violence prevention

program. Good records help employers determine the severity of the problem,

evaluate methods of hazard control, and identify training needs. Records can be

especially useful to large organizations and for members of a business group or

trade association who "pool" data. Records of injuries, illnesses, accidents,

assaults, hazards, corrective actions, patient histories, and training, among

others, can help identify problems and solutions for an effective program. 



The following records are important:

* OSHA Log of Injury and Illness (OSHA 200). OSHA regulations require entry on

the Injury and Illness Log of any injury that requires more than first aid, is a

lost-time injury, requires modified duty, or causes loss of consciousness.9

(This applies only to establishments required to keep OSHA logs.) Injuries

caused by assaults, which are otherwise recordable, also must be entered on the

log. A fatality or catastrophe that results in the hospitalization of 3 or more

employees must be reported to OSHA within 8 hours. This includes those resulting

from workplace violence and applies to all establishments. 

* Medical reports of work injury and supervisors' reports for each recorded

assault should be kept. These records should describe the type of assault, i.e.,

unprovoked sudden attack or patient-to-patient altercation; who was assaulted;

and all other circumstances of the incident. The records should include a

description of the environment or location, potential or actual cost, lost time,

and the nature of injuries sustained. 

* Incidents of abuse, verbal attacks or aggressive behavior which may be

threatening to the worker but do not result in injury, such as pushing or

shouting and acts of aggression towards other clients should be recorded,

perhaps as part of an assaultive incident report. These reports should be

evaluated routinely by the affected department. (See sample incident forms in

Appendix D ). 

* Information on patients with a history of past violence, drug abuse, or

criminal activity should be recorded on the patient's chart. All staff who care

for a potentially aggressive, abusive, or violent client should be aware of

their background and history. Admission of violent clients should be logged to

help determine potential risks. 

* Minutes of safety meetings, records of hazard analyses, and corrective actions

recommended and taken should be documented. 

* Records of all training programs, attendees, and qualifications of trainers

should be maintained. 



Evaluation

As part of their overall program, employers should evaluate their safety and

security measures. Top management should review the program regularly, and with

each incident, to evaluate program success. Responsible parties (managers,

supervisors, and employees) should collectively reevaluate policies and

procedures on a regular basis. Deficiencies should be identified and corrective

action taken. 



An evaluation program should involve the following: 



* Establishing a uniform violence reporting system and regular review of

reports. 

* Reviewing reports and minutes from staff meetings on safety and security

issues. 

* Analyzing trends and rates in illness/injury or fatalities caused by violence

relative to initial or "baseline" rates. 

* Measuring improvement based on lowering the frequency and severity of

workplace violence. 

* Keeping up-to-date records of administrative and work practice changes to

prevent workplace violence to evaluate their effectiveness. 

* Surveying employees before and after making job or worksite changes or

installing security measures or new systems to determine their effectiveness. 

* Keeping abreast of new strategies available to deal with violence in the

health care and social service fields as these develop. 

* Surveying employees who experience hostile situations about the medical

treatment they received initially and, again, several weeks afterward, and then

several months later. * Complying with OSHA and state requirements for recording

and reporting deaths, injuries, and illnesses. 

* Requesting periodic law enforcement or outside consultant review of the

worksite for recommendations on improving employee safety. 

* Management should share workplace violence prevention program evaluation

reports with all employees. Any changes in the program should be discussed at

regular meetings of the safety committee, union representatives, or other

employee groups. 



Sources of Assistance

Employers who would like assistance in implementing an appropriate workplace

violence prevention program can turn to the OSHA Consultation service provided

in their state. Primarily targeted at smaller companies, the consultation

service is provided at no charge to the employer and is independent of OSHA's

enforcement activity. (See Appendix E.) 



OSHA's efforts to assist employers combat workplace violence are complemented by

those of NIOSH (1-800-35-NIOSH) and public safety officials, trade associations,

unions, insurers, human resource, and employee assistance professionals as well

as other interested groups. Employers and employees may contact these groups for

additional advice and information. 

Conclusion

OSHA recognizes the importance of effective safety and health program management

in providing safe and healthful workplaces. In fact, OSHA's consultation

services help employers establish and maintain safe and healthful workplaces,

and the agency's Voluntary Protection Programs were specifically established to

recognize worksites with exemplary safety and health programs. (See Appendix E.)

Effective safety and health programs are known to improve both morale and

productivity and reduce workers' compensation costs. 



OSHA's violence prevention guidelines are an essential component to workplace

safety and health programs. OSHA believes that the performance-oriented approach

of the guidelines provides employers with flexibility in their efforts to

maintain safe and healthful working conditions.

 Return Home