By BOB TEDESCHI @bobtedeschi

NOVEMBER 20, 2015

Dr. Ronald Wyatt, an internist in Madison, Ala., entered an exam room to meet a new patient and his wife several years ago. When he walked in, the woman immediately pulled a framed photo from a large grocery bag.

It was the couple’s daughter, and Wyatt recognized her as his patient — one who had died two years earlier.

“I really can’t speak with you about this,” Wyatt recalled saying, his anxiety rising.

The father blocked the door, instructing the doctor: “You are not leaving this room.”

There were no alarms to set off, so Wyatt relented. Eventually, he opened his computer and showed, through patient records, how hard his team had worked to prevent their daughter’s death; he said he, too, had loved her. The father started weeping, then left peacefully. But it could have gone another way.

“Either one of them could’ve pulled a gun and shot me,” Wyatt said. “I had no way out of that room.”

It was a unique experience in Wyatt’s career. But at its essence, it was also a moment — filled with tension and seemingly ripe to explode in violence — that is disturbingly common in American clinics and hospitals. Those moments frequently lead to physical assaults when patients or family members suspect a medical error has taken place.

Conflicts between clinicians and patients and their family members have leapt onto the radar of health care administrators and policy makers this year. That’s partly the result of a traumatic episode in January in which a beloved Boston cardiac surgeon was killed by the son of a deceased patient. But it’s also because patient-on-clinician violence is on the rise, according to federal statistics.

Among the 26,000 significant injuries due to workplace assault in 2013, nearly 75 percent were reported in the health care and social services sectors, according to the Bureau of Labor Statistics.

Injuries caused by violence nearly doubled among nurses and nurse assistants from 2012 to 2014, and increased by smaller margins among doctors and other medical professionals over the same period, according to an April report by the Centers for Disease Control and Prevention.

Hospitals with a history of violence have responded by hiring more security officers and even buying technology to track the whereabouts of patients and personnel. But hospitals are by their nature open environments meant to convey an atmosphere of healing, not defensiveness, so they’re pursuing other strategies, as well.

Wyatt, for one, is helping to identify ways to stop the violence before it happens. As medical director of the health care improvement division at the Joint Commission, an independent organization that accredits health care institutions, he has been studying innovative ways in which institutions are tackling the issue.

They range from a massive and ongoing antiviolence program conducted by the Veterans Health Administration to more recent initiatives from the CDC and the Occupational Safety and Health Administration, which is involved in its own effort to study antiviolence programs in the health care system.

“There’s an acute effort here to come up with something robust around workplace violence prevention, and hold organizations more accountable,” Wyatt said.

Emergency room doctors and nurses, who are among the most frequent victims of patient attacks, said perpetrators are often mentally ill or under the influence of drugs or alcohol. But in other cases, otherwise perfectly reasonable individuals turn violent when being informed of a family member’s death or being refused narcotics.

Perpetrators typically fall into two categories — “affective,” or spontaneous, offenders, who are spurred by their immediate circumstances, and “predatory” offenders, who plan attacks methodically.

That’s an important distinction, conflict-resolution specialists said. While clinicians may be able to defuse the anger of affective perpetrators, they might endanger themselves trying to reason with predatory offenders.

The Veterans Health Administration initiative prepares for a full range of threats, said Kathleen McPhaul, who supervises the Department of Veterans Affairs’ Prevention and Management of Disruptive Behavior program.

The program offers four levels of behavioral-management training, starting with a basic program required of virtually every VA health care employee. A more specialized level of communication training is offered to those who are more likely to encounter verbal conflicts with patients.

Those who are more likely to encounter physically combative patients, meanwhile, learn how to escape a patient’s grip without hurting the patient or themselves, for instance. Others learn how to work in teams to contain a patient safely.

For the communication training, McPhaul said, staff members participate in role-playing exercises. “We’ve insisted the training be face-to-face,” she said, “because it’s very difficult to be good at this if you don’t do it in front of somebody.”

Outside the VA system, safety concerns have grown so pervasive that some communication training programs that never dealt with the issue of violence have been forced to do so. Such is the case at Brigham and Women’s Hospital in Boston, where Dr. Michael Davidson, the cardiac surgeon, was fatally shot earlier this year.

Courtesy: STAT


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