Promoting a Culture of Safety through Mitigating Workplace Violence with Early “Out of Control” Patient Interventions

Purpose:
The purpose was to initiate a Work Place Safety Bundle. Interventions included structured interdisciplinary education on de-escalation strategies, state laws, and regulatory guidelines; “out of control person” (Code Green) policy revision; and development of audit tools for event debriefing.

Significance:
Nurses are the most frequent targets of violence, with 80% experiencing violence during their career (Simons, 2011). 97.1% of physical violence is perpetrated by patients or relatives (Howell, 2011). Mitigating violence in the workplace is a regulatory priority and essential in a culture of safety.

Strategy and Implementation:
Since September 2010, 100% (n=78) Code Green events have been reviewed and debriefed with 591 staff in attendance. Two hundred three staff members across 21 departments attended additional Non-Violent Crisis training in 2011. Two levels of interventions were defined: Code Green and “Stat”. A “Stat” call is the need for immediate security team response for situation de-escalation, while a Code Green is a emergency response to a potentially violent interaction. A special team was developed to debrief and review every event on a monthly basis. Team members included security, hospital safety officer, social work, registered nurses and psychiatric professionals. An innovative auditing tool was developed to review de-escalation strategies and future learning opportunities as a result of the events. The audit tool was designed to incorporate regulatory compliance with potentially violent situations.

Evaluation:
Intervention levels were reviewed with 96% of Code Green meeting practice indications. The ratio of Stat calls to Code Greens is 4:1 demonstrating staff recognition of escalating situations and use of early intervention techniques. The audit tool demonstrates effectiveness of skill application.

Implications for Practice:
Appropriate use of de-escalation tactics improves compliance and promotes a non-violent workplace and a culture of safety. Innovative interdisciplinary teamwork enables staff to feel empowered to handle potentially violent situations. A safety culture is enhanced through staff knowledge and skills.