Hospital violence

VIOLENCE TOWARDS VIOLENCE TOWARDS HOSPITALS & DOCTORSHOSPITALS & DOCTORS

Medicolegal AspectsMedicolegal Aspects& Prevention& Prevention

Dr. AVINASH BHONDWEDr. AVINASH BHONDWE

PRESIDENT,PRESIDENT,

IMA, PUNEIMA, PUNE


VIOLENCE:VIOLENCE:Rough or injurious physical force, Rough or injurious physical force, action, or treatmentaction, or treatmentAn unjust or unwarranted exertion of An unjust or unwarranted exertion of force or power, as against rights or force or power, as against rights or lawslaws


WORKPLACE VIOLENCEWORKPLACE VIOLENCE::Violence often takes place during Violence often takes place during times of high activity times of high activity interaction with patients, such as interaction with patients, such as ADMISSION IN EMERGENCY WARDADMISSION IN EMERGENCY WARDPatient transportation. Patient transportation. Patient is involuntarily admitted, Patient is involuntarily admitted, BillingBillingHospital RulesHospital Rules


DURING ADMISSIONSDURING ADMISSIONS:-:-

EXPLAININIG GRAVE SITUATIONSEXPLAININIG GRAVE SITUATIONS

BAD PROGNOSIS, BAD PROGNOSIS,

COSTLY SURGERIES OR TREATMENTCOSTLY SURGERIES OR TREATMENT

ANAPHYLACTIC REACTIONSANAPHYLACTIC REACTIONS

UNEXPECTED CONSEQUENCES OF THE UNEXPECTED CONSEQUENCES OF THE TREATMENT, TREATMENT,

COMPICATIONS OF THE CONDITIONS COMPICATIONS OF THE CONDITIONS

DEATHDEATH


Patient transportation OR ShiftingPatient transportation OR ShiftingAssaults may occur when service is Assaults may occur when service is denieddeniedMay be a Doctor is not accompanying May be a Doctor is not accompanying during shiftingduring shiftingPatient dies before or during shiftingPatient dies before or during shiftingPatient dies at tertiary centre on or Patient dies at tertiary centre on or after shiftingafter shifting


Billing-Billing-

Not understanding the billing proceduresNot understanding the billing procedures

Claiming overchargingClaiming overcharging

Claiming Unexplained or/ and unwarranted Claiming Unexplained or/ and unwarranted chargingcharging

Inability to pay chargesInability to pay charges

Denial by hospital for treating the patient Denial by hospital for treating the patient or giving the deadbody for nonpaymantor giving the deadbody for nonpaymant


Hospital Rules-Hospital Rules-Advance PaymentAdvance Payment‘‘Office Permission’Office Permission’Prescribing Medicines, Appliances & Prescribing Medicines, Appliances & Materials to be purchased from Hospitals Materials to be purchased from Hospitals onlyonlyA health care worker attempts to set limits A health care worker attempts to set limits on eating, drinking, or tobacco or alcohol on eating, drinking, or tobacco or alcohol use.use.


What is workplace violence?What is workplace violence?Offensive language & AbusesOffensive language & AbusesThreats of assaults Threats of assaults Physical assaults Physical assaults Destruction of Building, Property & Destruction of Building, Property & Medical Equipments Medical Equipments Disrupting the hospital routine & Disrupting the hospital routine & treatment of other patients- emergency or treatment of other patients- emergency or non-emergencynon-emergencyHomicidal AttacksHomicidal Attacks


Some Examples of violenceSome Examples of violence Threats:Threats: Expressions of intent to cause harm, Expressions of intent to cause harm, including verbal threats, threatening body including verbal threats, threatening body language, and written threats.language, and written threats.Physical assaults:Physical assaults:

1.1. Non-Harmful Attacks-Non-Harmful Attacks- slapping, Blackening the slapping, Blackening the face, Spitting, Pulling Hair, Shovingface, Spitting, Pulling Hair, Shoving

2.2. HarmfulHarmful -From beating to rape, homicide, and -From beating to rape, homicide, and the use of weapons such as firearms, bombs, or the use of weapons such as firearms, bombs, or knives.knives.

3.3. Muggings:Muggings: Aggravated assaults, usually Aggravated assaults, usually conducted by surprise and with intent to rob.conducted by surprise and with intent to rob.


Case Reports:Case Reports:An elderly patient verbally abused a nurse An elderly patient verbally abused a nurse and pulled her hair when she prevented him and pulled her hair when she prevented him from leaving the hospital to go home in the from leaving the hospital to go home in the middle of the night. middle of the night. An agitated psychotic patient attacked a An agitated psychotic patient attacked a nurse, broke her arm, and scratched and nurse, broke her arm, and scratched and bruised her. bruised her. A disturbed family member whose father had A disturbed family member whose father had died in surgery at the Civil Hospital walked died in surgery at the Civil Hospital walked into the emergency department and fired a into the emergency department and fired a small-caliber handgun, injuring a nurse and small-caliber handgun, injuring a nurse and an emergency medical technician and an emergency medical technician and wounding the emergency physician wounding the emergency physician


Difference Other Workplaces Vs HospitalsDifference Other Workplaces Vs Hospitals

These circumstances of hospital violence differ These circumstances of hospital violence differ from the circumstances of workplace violence from the circumstances of workplace violence in general. in general.

In other workplaces such as Banks, Malls, In other workplaces such as Banks, Malls, General Stores and Taxi-Rikshaw, violence General Stores and Taxi-Rikshaw, violence most often relates to robbery.most often relates to robbery.

Violence in hospitals usually results from Violence in hospitals usually results from patients and from their family members who patients and from their family members who feel frustrated, vulnerable, and out of control. feel frustrated, vulnerable, and out of control.


Who is at risk?Who is at risk?

Doctors-from duty doctors, housemen, Doctors-from duty doctors, housemen, C.M.O.s to consultants & Super SpecialistsC.M.O.s to consultants & Super Specialists

Pathologist, Radiologists, SonologistsPathologist, Radiologists, Sonologists

SistersSisters

Ward-boys & AyahsWard-boys & Ayahs

Reception & Office Staff Reception & Office Staff

Security Guards & WatchmenSecurity Guards & Watchmen

Any Health care providerAny Health care provider


Where may violence occur? Where may violence occur? Violence may occur anywhere in the hospital, but it Violence may occur anywhere in the hospital, but it

is most frequent in the following areas: is most frequent in the following areas: Emergency roomsEmergency roomsSurgical WardsSurgical WardsPsychiatric wards Psychiatric wards Consulting RoomsConsulting RoomsWaiting rooms Waiting rooms Geriatric units Geriatric units Billing CountersBilling CountersReception CountersReception Counters


The effects of violenceThe effects of violence May range in intensity and include the following:May range in intensity and include the following:

Minor physical injuries Minor physical injuries Serious physical injuries Serious physical injuries Temporary and permanent physical disability Temporary and permanent physical disability Psychological trauma Psychological trauma Death Death Negative organizational outcomes such asNegative organizational outcomes such as

1.1. Low worker morale, Low worker morale, 2.2. Increased job stress, Increased job stress, 3.3. Increased worker turnover, Increased worker turnover, 4.4. Reduced trust of management and coworkers, Reduced trust of management and coworkers, 5.5. Hostile working environmentHostile working environment..


The risk factors for violenceThe risk factors for violence vary from hospital vary from hospital to hospital depending on location, size, and type to hospital depending on location, size, and type of care. Common risk factors of care. Common risk factors Working directly with volatile people, especially, Working directly with volatile people, especially, if they are under the influence of drugs or alcohol if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic or have a history of violence or certain psychotic diagnoses diagnoses Working when understaffed-especially during Working when understaffed-especially during meal times and visiting hours meal times and visiting hours Transporting patients Transporting patients Long waits for service Long waits for service Overcrowded, uncomfortable waiting rooms Overcrowded, uncomfortable waiting rooms Working alone Working alone


The risk factors for violence( contd..)The risk factors for violence( contd..)Poor environmental design Poor environmental design Inadequate security Inadequate security Lack of staff training and policies for Lack of staff training and policies for preventing and managing crises with preventing and managing crises with potentially volatile patients potentially volatile patients Drug and alcohol abuse Drug and alcohol abuse Access to firearms Access to firearms Unrestricted movement of the public Unrestricted movement of the public Poorly lit corridors, rooms, parking lots, Poorly lit corridors, rooms, parking lots, and other areas and other areas


MEDICOLEGAL ASPECTS IN PROPOSED MEDICOLEGAL ASPECTS IN PROPOSED ORDINANCEORDINANCE

1.1. DOCTORS- PRACTISING, FULL-DOCTORS- PRACTISING, FULL-TIMERS,PARTTIMERS,RESIDENTS,TIMERS,PARTTIMERS,RESIDENTS,

INTERNS,STUDENTSINTERNS,STUDENTS

2. NURSES- On duty Staff Nurses, 2. NURSES- On duty Staff Nurses, Student Nurses, Ayaas, Wardboys, Student Nurses, Ayaas, Wardboys, HelpersHelpers


3. Paramedical Staff: Lab. Assts., Lab 3. Paramedical Staff: Lab. Assts., Lab & Radiology staff, Hospital Social & Radiology staff, Hospital Social Workers, Physiotherapist, Dietician, Workers, Physiotherapist, Dietician, Counselers etc.Counselers etc.

4. HOSPITAL STAFF- Reception, 4. HOSPITAL STAFF- Reception, Billing, Administration, Security, Billing, Administration, Security, Maintenance Dept.Maintenance Dept.


Violence:Violence:VerbalVerbalPhysical but non- injuriousPhysical but non- injuriousCausing Injury – Simple & GrievousCausing Injury – Simple & Grievous

Any violence will be termed as Any violence will be termed as Cognizable including simple & verbalCognizable including simple & verbal

-Offense will be Non-Bailable-Offense will be Non-Bailable


Destruction-Destruction-

Hospital EquipmentHospital Equipment

Hospital FurnitureHospital Furniture

Premises & BuildingPremises & Building

Fine + Purchase CostFine + Purchase Cost


The conviction- The conviction- FINE- up to 5 Lakh + CostFINE- up to 5 Lakh + Cost SENTENCE- Up to 5 yearsSENTENCE- Up to 5 years Or BothOr Both

This will be in addition to other offences This will be in addition to other offences proved under IPCproved under IPC

The cost will be recovered as per Revenue The cost will be recovered as per Revenue Recovery- By auctioning the property of the Recovery- By auctioning the property of the convictconvict


Prevention Strategies for EmployersPrevention Strategies for EmployersDevelop a safety and health program that Develop a safety and health program that includes includes

1.1. Management commitment,Management commitment,2.2. Employee participation,Employee participation,3.3. Hazard identification, Hazard identification, 4.4. Safety and health training With knowledge of Safety and health training With knowledge of

Medico-legal implications of the behavior Medico-legal implications of the behavior 5.5. Hazard prevention, control, and reporting. Hazard prevention, control, and reporting.

Employers should evaluate this program Employers should evaluate this program periodically. Although risk factors for violence are periodically. Although risk factors for violence are specific for each hospital and its work scenarios, specific for each hospital and its work scenarios, employers can follow general prevention employers can follow general prevention strategies.strategies.


Environmental DesignsEnvironmental Designs

Develop emergency signaling, alarms, and Develop emergency signaling, alarms, and monitoring systems. monitoring systems.

Install security devices such as metal Install security devices such as metal detectors to prevent armed persons from detectors to prevent armed persons from entering the hospital. entering the hospital.

Install other security devices such as Install other security devices such as cameras and good lighting in hallways. cameras and good lighting in hallways.

Provide security escorts to the parking lots Provide security escorts to the parking lots at night. at night.


Design waiting areas to accommodate and Design waiting areas to accommodate and assist visitors and patients who may have assist visitors and patients who may have a delay in service. a delay in service. Design the triage area and other public Design the triage area and other public areas to minimize the risk of assault: areas to minimize the risk of assault: – Provide staff restrooms and emergency exits. Provide staff restrooms and emergency exits. – Install enclosed nurses' stations. Install enclosed nurses' stations. – Install deep service counters or bullet-resistant Install deep service counters or bullet-resistant

and shatterproof glass enclosures in reception and shatterproof glass enclosures in reception areas. areas.

Arrange furniture and other objects to Arrange furniture and other objects to minimize their use as weapons minimize their use as weapons


Administrative ControlsAdministrative Controls

Design staffing patterns to prevent Design staffing patterns to prevent personnel from working alone and to personnel from working alone and to minimize patient waiting time. minimize patient waiting time.

Restrict the movement of the public in Restrict the movement of the public in hospitals by card-controlled access. hospitals by card-controlled access.

Develop a system for alerting security Develop a system for alerting security personnel when violence is threatened. personnel when violence is threatened.


Behavior ModificationsBehavior Modifications

Provide all workers with training in Provide all workers with training in recognizing and managing assaults, recognizing and managing assaults, resolving conflicts, and maintaining resolving conflicts, and maintaining hazard awareness and understanding hazard awareness and understanding the practical & legal consequences of the practical & legal consequences of the behaviourthe behaviour


Dealing With the Consequences of Dealing With the Consequences of ViolenceViolenceViolence may occur in the workplace in Violence may occur in the workplace in spite of preventive measures. spite of preventive measures. Employers should be prepared to deal with Employers should be prepared to deal with the consequences of this violence by the consequences of this violence by providing an environment that promotes providing an environment that promotes open communication and by developing open communication and by developing written procedures for reporting and written procedures for reporting and responding to violence. responding to violence. Employers should offer and encourage Employers should offer and encourage counseling whenever a worker is counseling whenever a worker is threatened or assaulted threatened or assaulted


Safety Tips for Hospital WorkersSafety Tips for Hospital Workers

Watch for signals that may be Watch for signals that may be associated with impending violence:associated with impending violence:

Verbally expressed anger and frustration Verbally expressed anger and frustration

Body language such as threatening Body language such as threatening gestures gestures

Signs of drug or alcohol use Signs of drug or alcohol use

Presence of a weapon Presence of a weapon


Maintain behavior that helps diffuse Maintain behavior that helps diffuse anger:anger:Present a calm, caring attitude. Present a calm, caring attitude. Don't match the threats. Don't match the threats. Don't give orders. Don't give orders. Acknowledge the person's feelings (for Acknowledge the person's feelings (for example, "I know you are under stress"). example, "I know you are under stress"). Avoid any behavior that may be Avoid any behavior that may be interpreted as aggressive (for example, interpreted as aggressive (for example, moving rapidly, getting too close, moving rapidly, getting too close, touching, or speaking loudly touching, or speaking loudly


Be alert:Be alert:

Evaluate each situation for potential Evaluate each situation for potential violence when you enter a room or begin violence when you enter a room or begin to relate to a patient or visitor. to relate to a patient or visitor.

Be vigilant throughout the encounter. Be vigilant throughout the encounter.

Don't isolate yourself with a potentially Don't isolate yourself with a potentially violent person. violent person.

Always keep an open path for exiting-don't Always keep an open path for exiting-don't let the potentially violent person stand let the potentially violent person stand between you and the door between you and the door


Steps to take, if you can't defuse Steps to take, if you can't defuse the situation quickly:the situation quickly:

Remove yourself from the situation. Remove yourself from the situation.

Call security for help. Call security for help.

Report any violent incidents to your Report any violent incidents to your management. management.

Call for Police help with the Call for Police help with the permission of Managementpermission of Management


Prevention Strategies That Have Prevention Strategies That Have Worked in U.S.A. Worked in U.S.A.

A security screening system in a A security screening system in a Detroit hospital included stationary Detroit hospital included stationary metal detectors supplemented by metal detectors supplemented by hand-held units. The system hand-held units. The system prevented the entry of 33 handguns, prevented the entry of 33 handguns, 1,324 knives, and 97 mace-type 1,324 knives, and 97 mace-type sprays during a 6-month period. sprays during a 6-month period.


Prevention Strategies That Have Worked Prevention Strategies That Have Worked in U.S.A.in U.S.A.

A violence reporting program in the A violence reporting program in the Portland, Oregon, VA Medical Center Portland, Oregon, VA Medical Center identified patients with a history of identified patients with a history of violence in a computerized database.* The violence in a computerized database.* The program helped reduce the number of all program helped reduce the number of all violent attacks by 91.6% by alerting staff violent attacks by 91.6% by alerting staff to take additional safety measures when to take additional safety measures when serving these patients. serving these patients.


Prevention Strategies That Have Worked Prevention Strategies That Have Worked in U.S.A.in U.S.A.

A system restricting movement of visitors A system restricting movement of visitors in a New York City hospital used in a New York City hospital used identification badges and color-coded identification badges and color-coded passes to limit each visitor to a specific passes to limit each visitor to a specific floor. The hospital also enforced the limit floor. The hospital also enforced the limit of two visitors at a time per patient. Over of two visitors at a time per patient. Over 18 months, these actions reduced the 18 months, these actions reduced the number of reported violent crimes by 65%.number of reported violent crimes by 65%.


All hospitals should develop a All hospitals should develop a comprehensive violence prevention comprehensive violence prevention program. program. No universal strategy exists to prevent No universal strategy exists to prevent violence. violence. The risk factors vary from hospital to The risk factors vary from hospital to hospital and from unit to unit. hospital and from unit to unit. Hospitals should form multidisciplinary Hospitals should form multidisciplinary committees that include direct-care staff committees that include direct-care staff as well as union representatives (if as well as union representatives (if available) to identify risk factors in specific available) to identify risk factors in specific work scenarios and to develop strategies work scenarios and to develop strategies for reducing them.for reducing them.


All hospital workers should be alert All hospital workers should be alert and cautious when interacting with and cautious when interacting with patients and visitors. patients and visitors.

They should actively participate in They should actively participate in safety training programs and be safety training programs and be familiar with their employers' familiar with their employers' policies, procedures, and materials policies, procedures, and materials on violence prevention on violence prevention

Hospital violence

Health & Medicine

Transcript of Hospital violence