Handling Potentially Dangerous Patients in Healthcare Settings

Healthcare providers frequently encounter patients who are under stress, emotionally unstable, or physically unwell. This reality places providers at a higher risk of workplace violence than many other professions. While ensuring patient care remains the priority, providers must also be prepared to manage, mitigate, and protect themselves and others from potentially violent situations.

In 2020, 76% of workplace violence injuries occurred in the healthcare and social assistance industry. By 2021-2022, the rate of nonfatal injuries involving days away from work in healthcare was 14 per 10,000 full-time equivalents (FTEs), more than triple the rate for all industries combined. These statistics underscore the increasing prevalence of workplace violence in healthcare settings, highlighting the need for effective strategies to ensure the safety of both providers and patients.

Recognizing Risk Factors for Violence
A history of violence is the strongest predictor of future violence. Other contributing factors include:

• Intoxication (alcohol, drugs, or both)
• Delirium or delusions
• Suicidal intent
• Intense emotions such as fear, anger, or revenge
• Personality traits (explosive or antisocial behavior)
• Communication barriers, including language differences or intellectual disabilities

While some of these factors may be known in advance, many become apparent only in the moment. This unpredictability makes it essential for healthcare teams to remain vigilant and ready to act.

Emergency medicine providers often face the challenge of evaluating resistant or hostile patients. Federal EMTALA regulations require clinical evaluations for all patients, regardless of behavior. However, no clinician is expected to put their safety at risk to comply with this law. The primary concern should always be using all available means to protect healthcare staff, other patients, and the violent individual.

Hospitals and urgent care centers should have policies and resources in place to manage high-risk situations. This includes collaboration with behavioral health professionals, social services, law enforcement, and legal advisors for guidance on managing violent individuals, restraining orders, and treatment refusal cases.

For guidance on creating hospital policies related to patient violence, resources such as the American College of Emergency Medicine Workplace Safety Assessment and The Joint Commission's Workplace Violence Prevention Standards provide evidence-based recommendations. Additionally, OSHA has Preventing Workplace Violence in Healthcare guidelines¹ and literature such as Rosen’s Emergency Medicine and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide discuss strategies for managing violent patients.

Recognizing Warning Signs of Escalation
While the creation of policies within your practice setting are important and violence can sometimes appear impulsive and unpredictable, there are common warning signs which healthcare workers should be on the lookout for, such as:

Behavioral Indicators:

• Increased agitation: Pacing, restlessness, or difficulty staying still
• Hostile body language: Clenched fists, tightening jaw, or exaggerated gestures
• Verbal threats or loud speech: Sudden outbursts, escalating volume, or threatening remarks
• Disorganized thinking: Confusion, difficulty responding to questions, or paranoia

Environmental and Situational Indicators:

• Crowded or noisy environments: Overstimulation can contribute to agitation
• Long wait times: Patients frustrated with delays may become aggressive
• Unresolved grievances: Individuals who feel ignored or dismissed may escalate
• History of violent encounters: If previous encounters were contentious, future visits may be more volatile

Ignoring these signs can allow a situation to spiral out of control, but overreacting can also escalate tensions. Healthcare professionals must be trained to recognize these signals and use appropriate de-escalation techniques.

De-escalation Strategies: Evidence-Based Techniques
Effectively managing violent patients requires a structured approach that prioritizes safety while preserving patient dignity. De-escalation techniques help healthcare workers mitigate volatile situations and reduce the likelihood of physical confrontation. Below are key evidence-based strategies:

1. Verbal De-escalation: Using a calm, non-threatening approach can significantly reduce aggression. Techniques include:
   • Active listening: Demonstrating understanding with phrases like, "I hear you. It sounds like you're really upset."
   • Empathy and validation: "I can see why that would be frustrating. Let's work together to find a solution."
   • Offering choices: Giving the patient a sense of control by offering two acceptable options (e.g., "Would you like to talk in the hallway or stay here?")
   • Remaining calm and non-confrontational: Lowering your voice and maintaining a relaxed posture can help defuse tension.
2. Nonverbal Techniques: Body language can communicate safety and calmness:
   • Maintain an open stance, avoid crossing arms
   • Keep a safe physical distance (at least two arms' length)
   • Do not block exits, and position yourself near a clear escape route
   • Use slow and deliberate movements
3. Environmental and Staffing Consideration
   • Assign chaperones or additional staff when dealing with high-risk patients
   • Train staff to recognize early signs of agitation and act proactively
   • Ensure panic buttons or wireless alarms are easily accessible
   • Use video surveillance for deterrence and documentation
   • Implement color-coded wristbands or chart flags for patients with a history of violence
4. Medication and Physical Restraints
   • Chemical sedation (e.g., benzodiazepines or antipsychotics) may be necessary in extreme cases but should be used as a last resort
   • Physical restraints should only be used if the patient poses an immediate danger to themselves or others, and should be done according to legal and ethical guidelines

On top of the above strategies, it is important to remember that stress and violence in healthcare settings can affect staff wellbeing, and institutions should also consider staff mental health support, such as debriefing sessions and access to counseling services for those affected by workplace violence.

Understanding State and Federal Laws on Healthcare Workplace Violence
In response to the growing issue of workplace violence in healthcare, both federal and state governments have introduced new legislation aimed at protecting healthcare workers.

Federal Legislation and Organized Medicine:

• The Workplace Violence Prevention for Health Care and Social Service Workers Act, passed by the U.S. House of Representatives, mandates that the Occupational Safety and Health Administration (OSHA) establish national standards requiring healthcare and social service employers to implement workplace violence prevention plans.
• OSHA has also increased its enforcement efforts, requiring hospitals and healthcare facilities to provide training, reporting mechanisms, and preventive measures to safeguard staff.
• The American Medical Association (AMA) supports federal initiatives to reduce workplace violence, advocating for increased protections, funding for training programs, and legal measures to hold perpetrators accountable.
• The American College of Emergency Medicine is actively working to help further legislation to address workplace violence in the healthcare setting and has developed multiple resources for emergency departments to address this issue including a robust toolkit in conjunction with the Emergency Nurses Association.

State Legislation:

• Many states have strengthened penalties for assaulting healthcare workers. For example, California, Illinois, and New York have classified such assaults as felonies, ensuring stricter penalties for perpetrators.
• States like Oregon and Washington have enacted workplace violence prevention laws mandating healthcare employers to develop and implement comprehensive security plans, conduct violence risk assessments, and provide staff training on de-escalation techniques.
• Several states have introduced mandatory reporting requirements, requiring hospitals to track and report incidents of workplace violence to state health agencies.

These evolving laws underscore the importance of staying updated on legal requirements at both the state and federal levels. Healthcare providers should work closely with legal and compliance teams to ensure adherence to these laws and enhance workplace safety.

Final Thoughts
Managing violent patients is a complex but necessary skill for healthcare providers. Recognizing warning signs, employing de-escalation techniques, and ensuring institutional safety policies can significantly reduce risk. By focusing on patient care while maintaining provider safety, healthcare workers can better navigate these challenging situations.

¹ www.osha.gov/hospitals/workplace-violence

The information provided herein does not, and is not intended to, constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.

Article originally published in 2Q25 Copiscope.