Physical Safety from Violence in the Dental Practice
Kathleen M. Roman, M.S
As you think about upcoming clinical experience, remember that there are lots of different types of risk assessments. Here's one that you can't afford to overlook.
Safety plans address a variety of risks. Remember when you were little and every October your school celebrated Fire Prevention Month? Many of us still recall the visits of important dignitaries, like real firemen or Smoky the Bear, to our classrooms. Through educational programs aimed at kids, schools also encouraged parents to check for fire hazards in the home and to take steps to correct them. Today, millions of homes and businesses have fire extinguishers and smoke alarms, at least in part because of the benefits of a proactive national fire safety program.
Years later, because of local fire codes, you probably continue to benefit from this national program through an in-office fire safety plan. In addition, you may also have taken the safety approach a step further and implemented protection plans for bad weather and possibly even for earthquakes, depending on what part of the country you live in.
But there's another type of risk that you may not be prepared to deal with. What are you doing to protect yourself, your staff, and your patients from physical violence? Statistically, the odds are greater that you will be harmed by a violent person than by a powerful storm. According to a study by the Bureau of Labor Statistics (BLS), "health care and social service workers are frequent victims of violent assault at work." In some parts of the country, healthcare professionals are classified in the job category most at-risk to become victims of violent crimes.
The dental office isn't immune to violence. Over the past 15 years, the Joint Commission has received reports of 256 crimes in a variety of healthcare facilities. That may not seem like a lot but, interestingly, the majority of these crimes have occurred within the past five years. When this report was published, in June 2010, over 100 violent episodes had been reported just in the previous three years. This shows a significant increase with each ensuing year. In addition, the Joint Commission alert noted that the report numbers are likely quite low because of "significant under-reporting."
Much of the statistical information reported on violence in the healthcare environment is drawn from hospitals. Because the literature lacks statistics about assaults on office-based healthcare, it may not be a good idea to assume that the dental office is a safe haven. Rather, state and local crime monitoring agencies may be better resources for dentistry-specific statistics.
Evidence suggests that, once a dental office or worker is targeted by a violent offender, they may actually be at higher risk for the following reasons. First, the average dental office has fewer employees than the average medical office. Security experts remind their clients of the old adage, "there is safety in numbers." Second, the ratio of female to male employees is typically higher in dental practices than in many other healthcare settings. Violent individuals may feel safer acting out in an environment that is composed of a small group, almost all of whom are women. In addition, the upward trend in the number of female dental school graduates has contributed to a commensurate increase in the number of all-female dental offices.
How to begin: First, acknowledge the possibility that you, or the people you work with, can be victims of threatening or violent behavior. This is an unpleasant thought and one that most of us would rather ignore. But, take into consideration the fact that, even though you've probably never had a fire in your office, you are nonetheless prepared for the possibility that one might occur. Because of your school training, and local fire codes, this preparedness has become an accepted part of your business process. Continuing this line of thinking, just because you've never had a violent episode in your office doesn't mean that you never will. The time to develop a plan is before you need one.
Conduct a risk assessment. Include staff when you conduct a risk assessment. Violence can occur in a variety of ways and a team approach increases the odds of prevention or successful management. Keep in mind that several states have reported acts of domestic violence in the healthcare setting. Employees who are at risk of domestic violence may be even more vulnerable at work because the threatening individual knows where and when the intended victim is are most likely to be at work. Employers have a duty to take into account the possibility of such risks and utilize appropriate measures to manage them.
Here are just a few questions that might help you get started in assessing the physical risks associated with your practice:
- How secure are doors and windows, especially back doors or seldom-used hallway entrances?
- Must staff or patients leave the actual office in order to use a lavatory? What security measures need to be in place to protect them while they are outside the actual walls of the office?
- Is there need for a code lock system to reserve access to the lavatories only to those individuals who have been given a code? Is the code changed regularly?
- Are hallways adequately lit and does building management use cameras, employees, or hired security staff to survey the building and parking areas?
- Does staff education include required compliance with management of known security risks? Examples: "We never open the back door without first looking through the peephole;" "When working alone in the office, all doors must be kept locked;" or "After hours emergency calls from unknown individuals are referred to the local ER."
- Do employees typically park within view of the office windows? Are employees encouraged to walk out of the office together, especially in wintertime when it may be dark outside at the end of the business day?
- Are you prepared to deal with a variety of possible threats or violence? Examples: a) an irate patient or family member; b) a stranger; c) a former employee; d) a current employee – possibly someone who has just been fired; e) a family member of acquaintance of a current or former employee; f) a person who claims to be an investigator of regulatory auditor, but who refuses to produce proper identification; g) other examples that you and your staff may have experienced.
- Whose job will it be to talk with a threatening patient or an intruder?
- What conversational skills might be needed to help defuse verbal confrontations?
- Who would determine whether or not patients need to be moved from treatment areas or if people in waiting rooms need to be evacuated?
- Whose job will it be to call building security or the police?
- How will the incident be documented once it has been resolved? Who will conduct and ensure that a post-incident debriefing occurs? Will it include: a) assessment of how well the team managed the incident; b) de-stressing; c) fine-tuning the current process to help improve the team's performance in potential future events.
Walk through various scenarios with your staff. Discuss management strategies. Here is a real example. Late one Friday evening, a female dentist received a call from a man who claimed to be one of her patients and who begged her to come to her office to examine an injury he said he'd sustained in a fist fight. The dentist went to her office and opened it only to be attacked by a stranger who demanded money and prescriptions for drugs. Fortunately, her boyfriend arrived at the office and confronted the attacker who ran away. Had the attacker been armed or more combative, this incident might have had a catastrophic ending. In this case, the doctor might have advised the caller to go the hospital ED for an initial assessment and to call the hospital to report the possible arrival of the patient and that, based on an initial exam, she could be called in to see the patient.
Don't panic. Acknowledgement of the need for a security system should not make your staff fearful. Rather, having a plan and knowing when to swing into action can reduce anxiety. Once you identify possible risk exposures, you can implement responses to be used by you and your staff, including outreach to safety/security experts and/or local law enforcement professionals. Then, just as you conduct periodic fire prevention reviews, you can also be prepared to deter/manage threats to you or anyone associated with your practice. ■
Kathleen M. Roman, M.S., is risk management education leader for Medical Protective – the nation's oldest professional liability insurer, exclusively serving the healthcare professions since 1899. Kathleen can be reached at: kathleen.roman@medpro.com
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http://bookofods.com/content/view/print/678590
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U.S. Dept. of Labor Occupational Safety & Health Administration Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. 2004.
http://www.osha.gov/Publications/OSHA3148/osha3148.html
Washington State Department of Labor & Industries. Workplace violence in Health Care Settings. 2006. http://wa.gov/safety/Topics/AtoZ/wpvhealthcare.asp
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http://www.jointcommission.org/assets/1/18/SEA_45.PDF.
Op.cit.
The Joint Commission. Sentinel Event Alert. Issue 45: Preventing Violence in the Health Care Setting. June 2010.
http://www.jointcommission.org/sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting_/
Gillespie, G., L., Gates, D. M., Nutler, M., et al. Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies. Rehabilitation Nursing. Vol. 35, No. 5, Sept.-Oct. 2010.
http://www.rehabnurse.ord/pdf/rnj325.pdf
U.S. Dept. of Labor Safety and Health Topics: Workplace Violence.
http://www.osha.gov/SLTC/workplaceviolence/index.html
Additional Resources:
McNight's Long-Term Care News & Assisted Living. June 2010.
http://www.mcknights.com/recent-rise-in-healthcare-facility-violence-may-be-higher-than-statistics-show-joint-commission-warns/article/171820/
Center for Personal Protection & Safety: Workplace Violence in Health Care Settings. 2010.
http://www.fha.org/acrobat/JohnW/CPPSHealthcareWPV.pdf
Violence against Women at Work. Department of Health & Human Services on Women's Health. Posted May 18, 2011.
http://www.womenshealth.gov/violence-against-women-at-work.cfm