Violent attacks in hospitals on staff, patients, or visitors is increasingly a matter of concern. While the actual number of attacks in hospitals is inexact-there is no national reporting system by which hospitals in general, or psychiatric facilities in particular, must report incidents of violence -it is considered to be extensive. According to the Department of Justice's National Crime Victimization survey, mental health professionals rank seventh and mental health custodial workers rank tenth in the occupations most at risk for violent workplace crime. Other statistics reveal that more assaults occur in health care and social services than in any other industry. In U.S. public sector hospitals, risk of injury to staff from assault is higher than risk of injury from all causes combined in construction, agriculture, mining, manufacture, and transportation.1 A report of the Veterans Administration states that in the United States health care workers experience the highest rate of injuries from workplace assault.2
The Occupational Safety and Health Administration (OSHA), a federal agency charged with protecting the well-being of workers, requires reporting of workplace-related injuries-these statistics only reflect workers and do not include patients as victims. OSHA was enacted in 1970. Its data of the past decade reveals a total of 106 workplace-related homicides in hospitals. The type of workplace is not delineated -it includes hospital inpatient as well as outpatient and community settings, and is not specific as to psychiatric hospitals.3
Beginning in 1986, the International Association of Hospitals Security Survey has compiled crime statistics in hospitals. The reporting is voluntary, and the number of participating hospitals varies each year. During the last decade, the number of physical assaults per hospital has varied from a low of 2.41 to a high of 8.43. As with OSHA data, the type of hospital is not spelled out.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits most acute care hospitals as well as behavioral health facilities. Through its Sentinel event reporting system, data is collected on unexpected deaths occurring in hospitals. Most of the reports involve medical errors and patient suicides. Homicides are not singled out. Also, the reporting system is voluntary. Consequently, hospitals may choose not to report, as the information shared with JCAHO becomes public information and could be used against the facility in civil proceedings or accessed by the media. Facility licensing authorities may require reporting of patient deaths. However, this varies from state to state and no national repository of data is available.
If anything, the data on the incidence of violent attacks are under-reported. Internal incident reporting is protected from discovery, and therefore does not become public record. To avoid negative publicity, hospitals often cloak incidents of crime by not reporting it or by using confidential reporting mechanisms. The result is that the picture of hospital crime is skewed. The general sense, however, is that violent attacks in hospitals are increasing, particularly in psychiatric hospitals given the widespread use of illicit drugs and the institutionalization of individuals who are deemed to pose a danger to others.4
Most aggressive behavior is verbal rather than physical, indirect rather than direct, passive rather than active, except at the service delivery interface. Studies on assaults in hospitals tend to focus on the service recipient rather than the service provider as the source of the problem. Frustrating situations such as a denial or delay of needed or desired service, or invasion of privacy or personal space, may bring about aggressive behavior. As one patient put it, "Do I have to hit someone in order to be seen by a doctor?"
Attacks in psychiatric facilities
In fiction, the mental hospital is the last place to be for treatment of emotional disorders. …