CLINICAL SAFETY

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CLINICAL SAFETY IN NEUROLOGY
James Brasic, MD, MPH and Jerry
Ainsworth, MD, PhD
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ACKNOWLEGMENTS
This work is supported by the Department of
Psychiatry of Bellevue Hospital Center and the
New York University School of Medicine, The Essel
Foundation, Family and Friends of Chelsea
Coenraads, the National Alliance for Research on
Schizophrenia and Depression (NARSAD), the Rett
Syndrome Research Foundation (RSRF), and the
Tourette Syndrome Association, Inc. Dr. Brasic is
a member of the Medical Advisory Board of the
Tourette Syndrome Association of Greater
Washington in Silver Spring, Maryland. Abdul
Kalaff assisted with the preparation of the
visual presentation.
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• Violence directed towards clinicians appears to
  be increasing.

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• Health care workers experience close to two
  fifths of non-fatal assaults on employees in the
  United States.

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• Clinicians typically deny
• the existence of the risk
• of assault by patients.

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• Violent incidents are underreported due to
  multiple reasons.
• Staff fear blame for incidents
• Reporting takes time
• Staff feel that reporting is unimportant

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• Individual psychiatric inpatients may perpetrate
  as many as 7.9 violent incidents per patient.

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• On psychiatric units violence is
• likely to occur in corridors.
• Violent patients are likely to have
• much longer lengths of stay than
• nonviolent patients.

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• On psychiatric inpatient units
• violence is likely to be directed at
• staff members and other patients.
• Violent patients are likely to
• exhibit high levels of aggression
• and anxiety.

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Examples of Verbal Violence

• Abusive language
• Bullying
• Ethnic slurs
• Intimidation
• Ridicule
• Threatening gestures
• Threats of injury
• Threats of violence

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Manifestations of Physical Violence

• Biting
• Chasing
• Grabbing
• Hitting
• Kicking
• Poking
• Pulling hair
• Punching
• Pushing
• Scratching
• Slapping
• Spitting
• Swinging
• Throwing

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Clinicians at Risk of Assault

• Emergency Medical Technicians
• Home Health Aides
• Neurologists
• Nurses
• Physicians
• Psychiatrists
• Social Workers
• Protective Services

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• Emergency medical technicians are at risk of
  assault.
• Their uniforms may be confused with police
  uniforms.
• They may encounter their patients in isolated
  settings without protection.

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• Home health aides take care of patients in
• isolated settings without protection.
• They may be misinterpreted by patients as
• intruders.
• Clinicians must consider the safety of the
• aide before ordering home care.

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• Nurses are frequent victims of patient assault.
• 80 of nurses are assaulted in their careers.
• Assaults are likely to occur at the time of
• medication administration.
• Evening and night shifts are likely times for
• assault of nurses by patients.

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• Nurses experience violence not only from
  patients, but also from other nurses, nurse
  managers, and physicians.
• Nurses are angry when nurse managers and
  physicians fail to protect them from assault.

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• Neurologists are at risk of assault
• by patients.
• Patients may develop paranoid delusions about
  their neurologist.
• Patients and family may assault the neurologist
  for real or imagined morbidity or mortality.

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• Patients may attack their neurologist for
  denials of requests for disability and other
  benefits, and for excuses for absences from
  school and work.

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• Members of protective services
• are at risk of assault.
• Answering calls by teams of at least
• two may abort aggression by patients.

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• Social workers are at risk of violence.
• Patients who fail to immediately
• receive requests for insurance,
• housing, food, and other benefits
• may assault the social worker.

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Clinical Situations Associated with Violence

• Absence of escape routes
• Inadequate staff
• Malfunctioning equipment
• Portable furniture
• Portable objects
• Unobserved patients
• Untrained protective services

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Precipitants of Violence

• Electrolyte imbalance
• Grief
• Hypoxia
• Insufficient staff
• Long hospitalization
• Loss

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Triggers of Violent Episodes

• Anxiety
• Denial of patient request for admission
• Disrespect, actual or imagined
• Fear
• Frustration
• Involuntary hospitalization
• Hunger
• Job loss
• Lack of privacy
• Long wait
• Noise
• Pain
• Sleep deprivation

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• Clinicians must recognize their intuition that
  violence is imminent.
• If clinicians feel apprehensive in clinical
  situations, then they ought to follow their
  instincts and guard personal safety.
• Experienced clinicians follow their gut
  reactions that something serious is imminent.

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Signs of Impending Violence

• Flushed facies
• Hostility
• Impulsivity
• Loud outbursts
• Name calling
• Obscene language
• Opening and closing the fist
• Pacing
• Pointing
• Possession of a weapon
• Profane language

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Signs of Impending Violence

• Pushing furniture
• Restlessness
• Scars
• Slamming objects
• Smell of alcohol on breath
• Staring eyes
• Sudden movements
• Tattoos
• Tension
• Uncooperativeness
• Widened eyes

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Traits associated with violence

• Previous history of violence
• Age under 30
• Male gender
• Abuse and dependence on alcohol and other
  substances
• Alcohol intoxication
• Psychotic symptoms

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Conditions associated with violence

• Acute confusional state
• Acute organic psychosis
• Alcohol abuse and dependence
• Alcohol intoxication
• Antisocial personality disorder
• Bipolar disorder
• Borderline personality disorder
• Delirium
• Delusional syndromes
• Dementia
• Fire setting
• Grandiosity
• Head injury
• History of family violence

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Conditions associated with violence

• History of physical abuse
• History of sexual abuse
• History of violence to self or others
• Homelessness
• Impulsivity
• Learning disability
• Lower income
• Lower socioeconomic status
• Male sex
• Mental disorders
• Mental retardation
• Minority status
• Paranoid psychosis
• Poor social networks
• Single

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Conditions associated with violence

• Sex offender
• Substance abuse and dependence
• Schizophrenia
• Schizoaffective disorder
• Torture of animals
• Unemployment
• Youth

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Findings Suggesting Violence

• ?Access to guns and other lethal weapons
• Agitation
• Anger
• Delusions, persecutory
• Disinhibition due to head trauma
• Intoxication with alcohol and other substances
• Participation in gangs
• Poor impulse control
• Recklessness
• Risk taking
• Verbalization of command auditory hallucinations
  to perform violence
• Verbalization of intent to kill
• Verbalization of plan to take revenge
• Violence at home

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Strategies to avoid violence

• Do not interview or examine patients in offices
  without security guards.
• Install windows in the doors to examining rooms.
• Place notices that violence will not be allowed.
• Avoid furniture that can block exit from rooms.
• Equip examining rooms, offices, and nursing
  stations with panic buttons.
• Do not interview or examine patients in your
  home.
• Require patients to pass through metal detectors
  before entering
• clinical areas.

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Procedures to prevent violence

• Closed circuit television monitoring
• Panic buttons in all clinical areas
• Two-way communication systems

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Clinician Behavior to Abort Violence

• Keep patients in your visual field.
• Do not turn your back on patients.
• Make sure that patients do not invade
• your personal space within 4 to 6 feet.

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Adverse consequences of violence

• Feeling upset
• Blaming self
• Fear of caring for isolated patients
• Irritability
• Anger
• Headache
• Low worker morale
• Poor job satisfaction
• Poor worker retention
• Insecurity
• Career change
• Lost time from work
• Refusal to identify self to patients

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• Debriefing sessions are helpful
• immediately after violent episodes.
• Obtain a precise statement of what
• happened.
• Apply the principles of Critical
• Incident Stress Management.

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• Victims of violence are at risk to
• develop Post Traumatic Stress
• disorder.