The stabbing of a nurse that took place in a Los Angeles County, California hospital on April 20th, 2014, resulted in the serious injury of a nurse. The danger of increasing violence and attacks within hospitals was demonstrated by this and an unrelated incident at another Los Angeles County hospital that happened later that same morning. Both involved stabbings to nurses, though in the first case, the attacker used a knife after he bypassed security and in the second case, the attacker stabbed a nurse with a pencil.
By performing a root cause analysis of just one demonstrative case, solutions that can prevent similar issues (like the one that happened later that very day as well as many other recent cases of hospital violence) can be developed. We will use Cause Mapping, a visual diagram of cause-and-effect relationships, of this case as an example of hospital violence.
The first step in the Cause Mapping process is to describe the what, when, and where of an incident, and define the impacts to an organization’s goals. In this case, the employee safety goal is impacted by the serious injury to a nurse. The patient safety goal is impacted by the potential for injury to a patient. The patient services goal is impacted by the fact that a violent attacker was able to bypass a weapons screening area. It’s unclear from the information available whether other goals were impacted in this case. Once that is determined the “?” can be replaced with the actual impacts to the goals, or “none”.
It can be helpful to determine the frequency of a type of incident. Clearly, since about seven hours passed between two stabbings of nurses within the same county in California, the frequency of these types of attacks is much too high.
Next, cause-and-effect relationships are determined by beginning with an impacted goal and asking “Why” questions. In this case, the injury to the nurse was caused by multiple stabbings. The stabbings resulted from the nurse encountering a violent attacker and were impacted by the response time. (In this case, security was searching for the man after he bypassed the weapons screening and was alerted to his presence when the attacked nurse began to scream.) It is unclear how the man was able to bypass the weapons screening station, but ideally improvements that would decrease the possibility of entrants bypassing it in the future will be implemented.
Violence within hospitals has been increasing over recent years, believed to be due to a number of factors. In addition, nurses and other hospital personnel have noted the difficulty in determining the potential for an escalation of violence in patients and other visitors. According to the President of the Emergency Nurses Association, Deena Brecher, R.N.,”You need to be able to recognize when things are starting to escalate. We know our behaviors can help escalate a situation, not intentionally.”
Many nurses are calling for establishment of workplace violence plans that would provide nurses and other hospital workers tools to identify and de-escalate potentially violent behavior, as well as provide additional protections against these types of attacks. Some hospitals have begun using a mobile distress system, such as a help button worn around the neck that allows a worker to request backup in a situation that feels unsafe.
These solutions bring up an interesting discussion about prevention and blame. The solutions listed above all require action by the part of nurses or hospital workers. Many organizations attempt to determine the person to “blame” for a situation, and then assign corrective actions accordingly. Clearly, nobody is trying to imply that hospital workers are at fault for these violent attacks (blame) but are rather trying to provide tools within their sphere of control to reduce the risk of worker injury (prevention). Preventing all people prone to violence from entering a hospital, while theoretically more effective at solving the problem, is neither practical nor possible. Thus it is hoped that providing hospital workers additional tools will result in reduced injuries from hospital violence.
To view the Outline and Cause Map, please click “Download PDF” above. Or view the Workplace Violence Prevention for Nurses course offered by the Centers for Disease Control and Prevention (CDC).