Violence in Healthcare

According to the Occupational Safety and Health Administration (OSHA), healthcare workers have a higher risk of being injured as the result of workplace violence than workers in any other industry. Between 2002 and 2013, OSHA reported that the rate of injuries requiring time off work was four times higher among healthcare workers when compared with the private industry average. These rates are probably underestimated, as many workplace violence events are unreported. In a 2015 study comparing self-report with documentation of violent incidents, researchers found an overall rate of underreporting of 88%. 

Underreporting of violence in the workplace impedes prevention efforts because it limits the understanding of both the scope and nature of the violent acts. Some healthcare workers may forgo the submission of a workplace violence report in the hospital’s database because it is seen as ‘part of the job’. Healthcare workers may also be hesitant to report violent acts perpetrated by patients if they feel the acts were unintentional and the result of the patient’s condition. For example, a patient may become combative when coming out of anesthesia.

There are myriad reasons why workplace violence is prevalent in healthcare. Healthcare workers are routinely interacting with people who are under tremendous stress either personally or on behalf of a loved one. Confusion, delirium, and the influence of prescription and/or illicit drugs are also factors associated with workplace violence in healthcare settings.

Workplace violence has negative consequences beyond work days lost for the specific incident. In a study of home care workers, researchers found that exposure to workplace violence was associated with increased levels of stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001).

A query of the CHPSO database returned 2516 events containing the words “violent”, “violence” or “violently.” The image below is a visual representation of a word analysis associated with workplace violence found in the event reports. Please note that some words have been redacted due to profane and derogatory language, often related to race or sexual orientation. Content from the database required removal prior to dissemination is a testament to the volatility of conditions with which healthcare workers have to contend.

The majority of these events involved aggression toward staff from patients, less frequently from family members. Few events involved staff-to-staff or patient-to-patient aggression. Factors associated with these reports were commonly confusion, drug or alcohol intoxication, mental illness, and grief or concern related a loved one. Leaving, or wanting to leave, against medical advice (AMA) is a commonly reported event in the database, often associated with patients feeling that treatment or discharge was taking too long.

As of April 1, 2017, Cal/OSHA regulation, Workplace Violence Prevention in Health Care, went into effect (California Code of Regulations, Title 8, Section 3342). The regulation is comprehensive and includes a definition of workplace violence as well as numerous required elements including:

  1. Management Commitment and Worker Participation
  2. Worksite Analysis and Hazard Identification
  3. Hazard Prevention and Control
  4. Training
  5. Recordkeeping
  6. Program Evaluation

The regulation applies to work in the following health care facilities, service categories, and operations:

  • Health facilities
  • Home health care and home-based hospice
  • Emergency medical services and medical transport, including these services when provided by firefighters and other emergency responders
  • Drug treatment programs
  • Outpatient medical services to the incarcerated in correctional and detention settings

Employers with employees working in these operations must adopt a comprehensive workplace violence prevention program by April 1, 2018, that meets the requirements of the regulation.  However, several elements have earlier compliance dates.  For example, covered employers must have begun to maintain a violent incident log and recordkeeping as of April 1, 2017.  The required elements for the violent incident log are set forth in the regulation.  In addition, hospital employers were required to begin reporting specified incidents to Cal/OSHA through its on-line reporting portal beginning July 1, 2017. 

CHPSO will convene a safe table meeting on workplace violence for member hospitals on December 21 from 10:00 am – 11:00 am PST. The focus will be geared to rural hospitals but all members are invited to attend. Registration is available here.

Members of the California Hospital Association have members-only access to a number of resources and tools for the prevention of workplace violence. Visit the CHA website for more details. If you have questions about your status, contact CHPSO at


Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015). Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace health & safety, 63(5), 200. Available at:

Hanson, G. C., Perrin, N. A., Moss, H., Laharnar, N., & Glass, N. (2015). Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC public health, 15(1), 11. Available at:

Occupational Safety and Health Administration (OSHA). Worker Safety in Hospitals: Caring for our Caregivers Available at:

Occupational Safety and Health Administration. (2004). Guidelines for preventing workplace violence for health care social service workers. In Guidelines for preventing workplace violence for health care social service workers. OSHA. Available at:

Phillips, J. P. (2016). Workplace Violence against Health Care Workers in the United States. N Engl J Med, 2016(374), 1661-1669.  Available at: