Written by: Alan C. Lynch, CHPA-L, CHSP, HEM – October 22, 2024

The Occupational Safety and Health Administration (OSHA) has identified healthcare workers as being among the highest risk groups for workplace violence, but most of the attention up to this point has been on hospitals. Freestanding site healthcare workers also have this risk, and it may be somewhat elevated because police or security officers are not routinely assigned to these locations. A lack of public perception of security issues compared to hospitals may also be a factor.

Unfortunately, placing a dedicated protection officer at every site where a violent episode might occur is cost prohibitive. We at St. Luke’s estimate it would cost our organization more than $5 million per year if we provided a security officer at every one of our ambulatory care sites where there is the potential for violence. Reductions in patient care service reimbursements paid by insurers to healthcare organizations in recent years have made it difficult to afford adequate security staffing even on hospital campuses, let alone offsite facilities.

Certainly, regularly providing an officer at some locations is justified based on the results of proactive threat assessments, but the potential for workplace violence could escalate at any freestanding clinical site for any number of reasons.

Healthcare organizations should perform proactive threat assessments of all freestanding patient care sites, completing those with the highest service related risks first. In our experience, the following patient care services have had an increased risk for violence; some services may seem more obvious than others:

• Outpatient Behavioral Health
• Substance Abuse Rehabilitation
• Pain Management
• Occupational Medicine
• Urgent Care Centers
• Community Care Clinics
• Orthopedics
• End of Life/Palliative Care
• Family Medicine
• Neurology
• Oncology/Cancer Treatment
• Cardiology
• Blood Drawing Stations (due to low staffing and their operating hours)

Situations that Could Prompt Workplace Violence at Offsite Healthcare Facilities

• Medication abuse/drug seeking behavior
• Unfounded malpractice accusation
• Grief reaction/blame for family member’s death
• Unresolved chronic pain
• Pre-existing behavioral health issues
• Clinical findings negatively affecting disability claim
• Clinical findings adversely affecting patient’s employment
• Billing disputes/inability to pay
• Mandatory reporting requirements (suspected neglect and abuse)
• Care of the under-privileged
• Patient involuntarily discharged from practice for cause
• First visit of a patient with extensive criminal history
• Perception that caregivers are easily intimidated
• Decreased perception of security compared to a hospital
• Patient and/or family member inability to cope with stress

Workplace Violence Mitigation Strategies You Should Adopt

Freestanding patient care facility security plans are often developed in response to specific situations, but there are universal mitigation strategies that should be considered for most locations before an incident occurs. These are:

• One public entrance, with a camera recording everyone who enters. All other building entrances are secured or have controlled access.
• A barrier exists between receptionists and patients
• Access to the treatment area from the waiting room is controlled
• Examination tables are positioned in rooms so that patients are never placed between a caregiver and his or her escape route
• Sharp objects are secured and out of patient reach in treatment rooms
• At least one secure-in-place room has been identified
• Emergency escape plans are rehearsed by staff
• Panic alarm buttons or wireless personal alarms are available
• Violence prevention and response education has been provided

Since violence prevention education can encompass many subjects, listed below is what we include in our freestanding clinical site security education program:

• Identification of at risk clients
• Early warning signs of aggressive behavior
• How to avoid inadvertently escalating aggression
• Differences between customer dissatisfaction and inappropriate anger
• Simple aggression de-escalation techniques
• Trusting your instincts as to the potential for harm
• Proactive notification of police (no permission needed)
• Police discretion – police don’t always have to arrest
• Pre-staging “bad news” discussions with patients
• Identifying secure-in-place locations and safe rooms
• Fundamental response to an active shooter situation

Clinicians Have Options When Dealing With Drug Seekers

Physicians and other practitioners authorized to write prescriptions are also provided with education on how to manage aggressive drug seekers who threaten, verbally infer or non-verbally express a willingness to harm clinicians if their demands are not met.

Many practitioners believe their only options are to refuse so they protect their license, which means they are taking the risk of being harmed, or to write an unnecessary prescription, which violates their professional ethics. However, practitioners do have another option.

Related Article: Drug Diversion in Healthcare: Video and Access Control Practices That Make a Big Difference

In working with our county district attorney, we learned that if a practitioner reasonably believes he or she will be harmed if he or she does not comply with a drug seeker’s request, the practitioner may issue the script and then call the police to report that they were criminally coerced. If a specific verbal threat was made, it is a rather simple matter of reporting to the police what was said by the patient. If the threat was inferred or communicated non-verbally, the practitioner needs to describe any threatening non-verbal gestures or cues given by the patient, and the situation that created the safety concern (e.g. alone with patient, patient’s size, gender, fitness, etc.).

Police refer to this as the “totality of the circumstances,” which helps to justify a chosen course of action taken by a person who was criminally coerced. The practitioner needs to document the incident as soon as possible to capture important details that may be quickly forgotten. The documentation is even more credible if it is included in the patient’s medical record.

Charges do not have to be pressed if the practitioner is satisfied with police contacting the patient. The patient is unlikely to repeat the behavior at the same location after being contacted by the police, even if they are not arrested. This solves the issue of developing a reputation for being a place to get drugs on the street and avoids having the practitioner place him or herself at risk or compromise his or her professional standing.

Consider the Use of Safe Rooms and Securing-In-Place

Secure-in-place locations and safe rooms should be designed proportionately to the risk. Out-of-control assaultive persons are an everyday risk, but the risk of an active shooter is far less common. Depending on a specific risk/benefit analysis, an organization may elect to create rooms that can resist bullet penetration or protect against severe weather.

In any case, all freestanding locations should have a room where staff can flee from a physically assaultive person. These rooms can also be used to flee from armed persons if staff are trained where to position themselves to minimize the possibility of being struck by a bullet. At a minimum, basic secure-in-place locations should be lockable from the inside, resistant to being forced open (solid wood or metal door in a metal frame), have hinge pins protected against removal, have no exterior windows or limited visibility/access from the outside and be equipped with a telephone or alarm mechanism to summon for help.

There already may be ideal spaces that could serve as ready-made safe rooms. Radiology imaging rooms are a good example because they have lead-lined walls and doors that are naturally resistant to bullet penetration. Additionally, these rooms usually have a phone and no outside windows.

To help staff identify safe rooms and secure-in-place locations during high stress situations, St. Luke’s has developed a wall-mounted sign modeled after the types used to help staff locate fire alarm pull stations and fire extinguishers at a distance down a corridor. These signs display our corporate logo on a yellow background, but don’t have wording that tips off the uninitiated as to their meaning. Employees are trained to look for these signs, and the signs also help to serve as a continual reminder where to secure in place during a dangerous situation.

Panic Buttons Can Be Cost Effective

Panic buttons are another item to discuss in some detail. Internet protocol (IP) addressable systems that generate computer screen “pop-up” alarm messages to remote PC workstations from front line locations are cost effective alternatives to hardwired panic alarms. The cost of having to install and pay central station monitoring fees for many individual alarm systems is avoidable by using one IP-based software solution.

It is important to note, however, that if an intrusion alarm system is currently in place, only a minor installation cost would be charged to add a panic alarm to an existing system, and this is preferred over an IP solution. Hardwired panic alarm systems tend to be more reliable; whereas IP-based systems have more potential for failure due to technological complexity. Monthly testing and equipping of multiple computer workstations as a redundancy helps to increase operational reliability of IP systems. As always, investments in security technology need to be proportional to the risk.

Assess Specific Threats as They Arise

When a patient threatens a caregiver at a freestanding site or there is cause to believe a patient has the capacity to harm, St. Luke’s performs an interdisciplinary threat assessment of the person and factors involved using a tool developed by the organization’s Workplace Violence Prevention Committee.

Potential Protective Strategies

• Relocate the target/victim
• Disseminate the suspect’s description and photograph if available
• Disseminate the suspect’s vehicle description
• Redirect phone calls and identify a single point of contact
• Create a specific staff emergency response plan
• Rehearse the emergency response plan
• Flag patient chart
• Send out a “Be on the lookout” message
• Increase patrols
• Have security supervise the appointments
• Post unarmed security officer for early identification and warning
• Request extra police patrols
• Notify the suspect’s probation/parole officer
• Hire off duty police officer for post assignment
• Make special parking arrangements and recommend varied routes to target/victim
• Obtain a restraining order
• Send trespass notice/Letter of discharge from service
• Stage bad news meeting
• Consider your organization’s duty to warn obligations
• Provide personal safety escorts
• Change shift – flex work hours
• Implement a temporary lockdown
• Create temporary passwords and codes for communication
• Refer the suspect to behavioral health
• Engage a workplace violence management specialist
• Request arrest or involuntary behavioral health commitment
• Request for release-from-custody notification

This tool identifies the potential aggressor’s type of motivation and threat, risk scale, and evaluates the patient’s aggravating and stabilizing situational factors. These factors include criminal history, substance abuse, employment status, family stability, weapons familiarization and 15 other factors. Based on the totality of these factors, a security mitigation plan is developed and may deploy any combination of protective strategies (see sidebar).

Threats to personal safety at freestanding care sites are not limited only to situations involving patients. These sites may have other security vulnerabilities, such as elevated crime rates in the surrounding neighborhood. These vulnerabilities may be amplified because freestanding sites do not have the same protective atmosphere as a hospital.

Organizations must also be prepared to respond to emerging threats, such as terminating a disruptive worker or protecting an employee who recently left an abusive relationship. Many of the same processes used to manage routine patient risks can also address emerging non-patient situations.

A security professional should implement a program as if their own family members’ safety depended upon it.

Alan C. Lynch, CHPA-L, CHSP, HEM was formerly the network director for safety and security at St. Luke’s University Health Network in Bethlehem, Pa. He is now a life safety code inspector for the Joint Commission. This article was originally published in 2016, but the recommendations still apply today.

Note: The views expressed by guest bloggers and contributors are those of the authors and do not necessarily represent the views of, and should not be attributed to, Campus Safety.

If you appreciated this article and want to receive more valuable industry content like this, click here to sign up for the Campus Safety FREE digital newsletters!