Be prepared to respond to potential violence in your workplace
Karen A.Santucci, M.D., FAAP
Pediatricians and the Law
You’re working in a busy emergency department (ED) or pediatric office, and the tension
in the air is almost palpable. Your nurse approaches frantically signaling an escalating
situation in exam room 5. The parents are irate and have become threatening toward
staff. You try to remain calm, get a semblance of the facts, and with some degree
of confidence and many sets of staring eyes, steadfastly approach the exam room. You
take a deep breath, knock on the door and enter the room. Immediately, you feel physically
threatened by two angry adults exhibiting limited self-control.
Having a step-by-step protocol to keep your employees, patients and others nearby
safe will help you think clearly and function effectively when faced with these challenging
situations. Such a protocol likely will reduce anxiety and may save lives.
Following are strategies to use in potentially violent situations in a pediatric office,
health care clinic, ED or hospital setting.
Before you enter the room
Remove your stethoscope, necktie or scarf to keep them from being a strangulation
risk. Empty your pockets of trauma shears and other sharp items that could be used
as a weapon.
Notify an employee to stand by in case help must be summoned per the protocol.
Use clear, calm, caring communication
Upon entering the room, use a gentle and empathetic voice to express concern and a
desire to help. Perhaps offer an apology in a calm voice. The apology is not intended
to be an admission of guilt, but certain phrases can reduce tension. “I am very sorry
that things have been so difficult today.” “I am so glad my nurse called me over.”
“I would really like to try to help.” Other messages to convey are “You must be very
concerned about your baby.” “I can see that you love her very much.” “Let’s see what
we can do together to make things better.”
Offering a seat, a box of tissues or glass of water can be comforting and may diffuse
the tension. Such gestures show you as a caretaker, not an adversary.
Use a qualified medical interpreter (in person or by telephone) for families with
limited English proficiency. Use a family member to translate only if there are no
other options and the situation is urgent. Speak slowly and clearly and maintain eye
contact. Pause to allow the family an opportunity to process the information and respond.
Include experts, if available
If you’re in the ED, involving the child’s pediatrician who may have a longstanding
relationship with the child and family can calm the situation.
Secure intervention from a clinical social worker or chaplain, if one is onsite.
Implement protocols and panic buttons
Instituting a clear protocol on what to do and how to do it is vital. Include key
contact names and numbers for resources. Have the action steps on laminated cards
and immediately available to employees.
Likewise strategically placed “panic buttons” to silently alert security, local police
or protective services can save lives. In extreme situations, it is advisable to activate
them before entering the patient’s room. Having someone poised to use them should
the situation deteriorate is another option. Most hospitals have these devices. Since
they are inexpensive, they can be installed in pediatric offices and clinics. Place
them in several locations such as the front desk, physicians’ work room, laboratories
and other central locations easily accessible to staff, but not curious children.
Contacting help, documenting incidents
Don’t hesitate to contact local police if a threat is made to you or another person
or if any damage has been done to hospital or office property. These actions may be
considered breach of peace, assault or destruction of property.
In some jurisdictions, a person is guilty of breach of the peace in the second degree
when, with intent to cause inconvenience, annoyance or alarm, or recklessly creating
a risk thereof in a public place: 1) engages in fighting or in violent, tumultuous
or threatening behavior; or 2) assaults or strikes someone else; or 3) threatens to
commit any crime against another person or that person's property; or 4) exhibits,
distributes, posts up or advertises offensive, indecent or abusive matter concerning
any person; or 5) uses abusive or obscene language or makes an obscene gesture; or
6) creates a hazardous or physically offensive condition by any act that such person
is not licensed or privileged to do.
Depending on the jurisdiction, aggravated assault or aggravated battery may be charged
when a person has the intention to cause physical injury with a weapon or dangerous
instrument. A person can be charged if recklessly engaging in conduct that shows extreme
indifference to human life. Depending on the charges, he or she may be incarcerated,
fined, placed on probation or mandated to provide community service, if convicted.
Notify child protective services. Family members demonstrating aggression and violence
may behave similarly in the privacy of their home, placing the child at increased
risk of non-accidental trauma/child abuse.
Inform the proper person at your hospital. Many institutions have a zero tolerance
policy for threats and may take legal action.
Create a narrative report about the incident. Follow up with a certified letter to
the party involved indicating the facts of the situation, the outcome of the confrontation
and the risks of future acts. If there are irreconcilable differences and you work
in an ambulatory setting where there is the expectation of continuity of care, you
may consider severing the doctor-patient relationship. Follow all relevant legal requirements
for such terminations.
Document the incident in the patient’s medical record. The best predictive marker
of impending violence is a history of violence. Flagging the record helps anticipate
problems at future visits.
Dr. Santucci is a member of the AAP Committee on Medical Liability and Risk Management.