《医疗和社会服务工作者预防工作场所暴力指南》（上）（美国劳工部职业安全与健康署制定）

医院暴力（Hospital violence）是工作场所暴力（Workplace violence）的一种形式，它的受害者可以是医疗场所内任何一位人员。医院暴力不仅仅威胁医生、护士，也可以危及医院管理人员、病人、病人家属乃至医院内的路人，所有在医院这一公共场所的人都可能是医院暴力的受害者。如果对医院暴力行为采取姑息态度，按照“破窗理论”，这种纵容会让更多的人受到伤害。美国劳工部关于工作场所暴力的预防指南中指出，如果可以确定工作场所暴力的危险因素，雇主采取适当的防范措施可以预防暴力的发生或者能将伤害降低到最低程度，其中最佳的预防措施就是对工作场所暴力采取零容忍政策。

要制定医院的工作场所暴力防范制度和计划；鼓励和支持医护人员对伤害事件的报告；预防和化解冲突或攻击性行为的方法；如何识别和处置敌意好斗之人以及非暴力性反应；愤怒管理技巧；解决冲突的技能与技巧；压力管理与放松技巧；保安制度与报警系统的使用；个人安全措施与自卫；对受害者的支持与救助等等。

以下是指南的全部内容，目前以英文为主。等待大家志愿翻译。

Contents：

Notice

Acknowledgments

Introduction

Overview of Guidelines

Violence Prevention Programs

    Management Commitment and Employee Involvement

    Worksite Analysis

    Hazard Prevention and Control

    Safety and Health Training

    Recordkeeping and Program Evaluation

Conclusion

References

OSHA assistance

    Safety and Health Program Management Guidelines

    State Programs

    Consultation Services

    Voluntary Protection Programs (VPP)

    Strategic Partnership Program

    Alliance Programs

    OSHA Training and Education

    Information Available Electronically

    OSHA Publications

    Contacting OSHA

OSHA Regional Offices

Appendices Appendix A: Workplace Violence Program Checklists

Appendix B: Violence Incident Report Forms

Appendix C: Suggested Readings

Incidence rates for nonfatal assaults and violent acts by industry, 2000 Incidence rate per 10,000 full-time workers
	Private Sector Overall	Health Services Overall	Social Services	Nursing & Personal Care Facilities
Source: U.S. Department of Labor, Bureau of Labor Statistics. (2001). Survey of Occupational Injuries and Illnesses, 2000.

• The prevalence of handguns and other weapons among patients, their families or friends;
• The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals;
• The increasing number of acute and chronic mentally ill patients being released from hospitals without follow-up care (these patients have the right to refuse medicine and 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;
• Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;
• The increasing presence of gang members, drug or alcohol abusers, trauma patients or distraught family members;
• Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients;
• Isolated work with clients during examinations or treatment;
• Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);
• Lack of staff training in recognizing and managing escalating hostile and assaultive behavior; and
• Poorly lit parking areas.

• Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions. Ensure that managers, supervisors, coworkers, clients, patients and visitors know about this policy.
• Ensure that no employee who reports or experiences workplace violence faces reprisals.⁽⁶⁾
• Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and measure progress.
• Outline a comprehensive plan for maintaining security in the workplace. This 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. Ensure that adequate resources are 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 issues such as preserving safety, supporting affected employees and facilitating recovery.

• Management commitment and employee involvement;
• Worksite analysis;
• Hazard prevention and control;
• Safety and health training; and
• Recordkeeping and program evaluation.

• Demonstrating organizational concern for employee emotional and physical safety and health;
• Exhibiting equal commitment to the safety and health of workers and patients/clients;
• Assigning responsibility for the various aspects of the workplace violence prevention program to ensure that all managers, supervisors and employees understand their obligations;
• Allocating appropriate authority and resources to all responsible parties;
• Maintaining a system of accountability for involved managers, supervisors and employees;
• Establishing a comprehensive program of medical and psychological counseling and debriefing for employees experiencing or witnessing assaults and other violent incidents; and
• Supporting and implementing appropriate recommendations from safety and health committees.

• Understanding and complying with the workplace violence prevention program and other safety and security measures;
• Participating in employee complaint or suggestion procedures covering safety and security concerns;
• Reporting violent incidents promptly and accurately;
• Participating in 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; and
• Taking part in a continuing education program that covers techniques to recognize escalating agitation, assaultive behavior or criminal intent and discusses appropriate responses.

• Analyzing and tracking records;
• Screening surveys; and
• Analyzing workplace security.

• Departments;
• Units;
• Job titles;
• Unit activities;
• Workstations; and
• Time of day.

• 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 (for example, those with psychiatric conditions or who are disoriented by drugs, alcohol or stress); physical risk factors related to building layout or design; isolated locations and job activities; lighting problems; lack of phones and other communication devices; areas of easy, unsecured access; and areas with previous security problems.
• Evaluate the effectiveness of existing security measures, including engineering controls. Determine if risk factors have been reduced or eliminated and take appropriate action.

• 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. Arrange for a reliable response system when an alarm is triggered.
• Provide metal detectors—installed or hand-held, where appropriate—to detect 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, triage and admitting areas 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 who "act out" and establish separate rooms for criminal patients.
• Provide comfortable client or patient waiting rooms designed to minimize stress.
• Ensure that counseling or patient care rooms have two exits.
• Lock doors to staff counseling rooms and treatment rooms to limit access.
• Arrange furniture to prevent entrapment of staff.
• Use minimal furniture in interview rooms or crisis treatment areas and ensure that it is lightweight, without sharp corners or edges and affixed to the floor, if possible. 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, both indoors and outdoors.
• Replace burned-out lights and broken windows and locks.
• Keep automobiles well maintained if they are used in the field.
• Lock automobiles at all times.

• 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. Give police physical layouts of facilities to expedite investigations.
• Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrences.
• Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary.
• 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 to deal with aggressive behavior. Follow written security procedures.
• Ensure that adequate and properly trained staff are available to restrain patients or clients, if necessary.
• Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time.
• Ensure that adequate and qualified staff are available at all times. The times of greatest risk occur during patient transfers, emergency responses, mealtimes and at night. Areas with the greatest risk include admission units and crisis or acute care units.
• 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 or gang activity. Make copies available at security checkpoints, nurses' stations and visitor sign-in areas.
• Review and revise visitor check systems, when necessary. Limit information given to outsiders about 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. Do not allow employees to enter seclusion rooms alone.
• Establish policies and procedures for secured areas and emergency evacuations.
• Determine 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. Keep in mind patient confidentiality and worker safety issues. Update as needed.
• Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions).
• Use case management conferences with coworkers 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 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.
• Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients.
• Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations. Urge community workers to carry only required identification and money.
• Survey the facility periodically to remove tools or possessions left by visitors or maintenance staff that 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. Ensure that parking areas are highly visible, well lit 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.
• Advise staff to exercise extra care in elevators, stairwells and unfamiliar residences; leave the premises immediately 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 their whereabouts throughout the workday. Have the contact person follow up if an employee does not report in as expected.

• Short- and long-term psychological trauma;
• Fear of returning to work;
• Changes in relationships with coworkers and family;
• Feelings of incompetence, guilt, powerlessness; and
• Fear of criticism by supervisors or managers.

• 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 to prevent or diffuse volatile situations or aggressive behavior, manage anger and appropriately use medications as chemical restraints;
• A standard response action plan for violent situations, including the availability of assistance, response to alarm systems and communication procedures;
• Ways to deal with hostile people other than patients and clients, such as relatives and visitors;
• Progressive behavior control methods and safe methods to apply restraints;
• 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;
• Information on multicultural diversity to increase staff sensitivity to racial and ethnic issues and differences; and
• Policies and procedures for obtaining medical care, counseling, workers' compensation or legal assistance after a violent episode or injury.

• OSHA Log of Work-Related Injury and Illness (OSHA Form 300). Employers who are required to keep this log must record any new work-related injury that results in death, days away from work, days of restriction or job transfer, medical treatment beyond first aid, loss of consciousness or a significant injury diagnosed by a licensed health care professional. Injuries caused by assaults must be entered on the log if they meet the recording criteria. All employers must report, within 24 hours, a fatality or an incident that results in the hospitalization of three or more employees.⁽⁸⁾
• Medical reports of work injury and supervisors' reports for each recorded assault. These records should describe the type of assault, such as an unprovoked sudden attack or patient-topatient 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 work time that resulted and the nature of injuries sustained. These medical records are confidential documents and should be kept in a locked location under the direct responsibility of a health care professional.
• Records of incidents of abuse, verbal attacks or aggressive behavior that may be threatening, such as pushing or shouting and acts of aggression toward other clients. This may be kept as part of an assaultive incident report. Ensure that the affected department evaluates these records routinely. (See sample violence incident forms in Appendix B.)
• Information on patients with a history of past violence, drug abuse or criminal activity recorded on the patient's chart. All staff who care for a potentially aggressive, abusive or violent client should be aware of the person's background and history. Log the admission of violent patients to help determine potential risks.
• Documentation of minutes of safety meetings, records of hazard analyses and corrective actions recommended and taken.
• Records of all training programs, attendees and qualifications of trainers.

• 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 illnesses, injuries 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 how well they work;
• 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 they develop;
• Surveying employees periodically to learn if they experience hostile situations concerning the medical treatment they provide;
• Complying with OSHA and State requirements for recording and reporting deaths, injuries and illnesses; and
• Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving employee safety.