That was the message delivered Wednesday by Monica Cooke, a mental health registered nurse and risk management consultant, during a chat hosted by the American Society for Healthcare Risk Management of the American Hospital Association. Cooke notes that more than half of emergency department nurses experience physical or verbal violence in a given week, and the majority do not report the incident.

The costs of such assaults are significant to the hospital, Cooke says, including lost productivity, potential litigation, property damage and diminished public image. She estimates that the cost borne by the hospital in the aftermath of a violent incident is 60 times greater than it would be to invest in violence prevention programs beforehand.

Patient experience should never trump the staff’s safety, Cooke says, and hospitals must foster the mindset that, as in airports, any type of abuse against their staff is never tolerated. When people fly, they know as soon as they walk in that they can’t have weapons, and if they step out of line, security will be upon them in a moment’s notice.

“We need to be a little more proactive,” Cooke says. “When people walk in our door, they [should] know that this is not a place that they can act out, or steps will be taken to contain it. That’s not always the case.”

As a risk management expert, Cooke listed some of the biggest factors that can lead to violence and that hospital staff should be aware of: drugs and alcohol, psychiatric conditions, long waits for service, poor staff attitudes, inadequate training, and limits on food and drink consumption. She stressed that leadership’s commitment is an essential first ingredient to beginning to move toward a safer environment for hospital employees.

Cooke listed four universal precautions that hospitals must take to begin making that shift and building a culture of safety: They are:

  1. Zero tolerance concept. The organization accepts that aggression may happen, and when it does, we’re not going to tolerate it. We are going to have systems, processes and people in place that are going to intervene at the lowest possible level when there is an escalation. To Cooke, that’s the basis of this concept. Zero tolerance doesn’t mean agressive behavior is not going to happen, but rather, when it does, it’s not going to be tolerated.
  2. Recognize escalation and intervene immediately. This is really the goal. We need to get there quickly and we need to intervene. Staff need to understand and know when the potential for an aggressive act begins to escalate. We shouldn’t ignore somebody who is threatening or being aggressive. We need to provide distractions that often can be helpful for people who are beginning to become agitated. We need a calm, directive approach, to maintain distance and always make sure that staff are in a position to run and not get backed up into a corner.
  3. Institute a culture of reporting. This is something that takes a lot of effort on the part of risk, quality and individual department managers. We need staff to understand that when they report, they are providing information that can assist them in gaining resources to help them with particular issues — in this case, aggression or violence. There are lots of reasons for the underreporting. “I understand it,” Cooke says. “I’m a nurse. But I have to understand that if I don’t report an incident, then nobody will ever know and there won’t be any attention paid to it.”
  4. Debrief all events. Debriefing is used by high-reliability organizations and, Cooke bemoans, “Why we are so hesitant to use it routinely in health care is just beyond me.” Behavioral health is probably the one area in which we’ve used it longer than in other areas, but it should be routine, constructive and without blame. It also should encourage discussion of the event so that we can identify areas that need improvement and then share lessons learned across the board. Experienced risk managers understand that this is how we get people to function better and mitigate risk.

For more on how hospitals are working to both prevent and treat violence in their communities, be sure to check out the American Hospital Association’s resource page on the topic. Plus, watch for continuing coverage on the AHA’s Hospital’s Against Violence initiative in the print edition of Hospitals & Health Networks and at