Date of incident: April 2015
Notice of incident number: 2015157580019
Employer: Public health care provider

Incident summary
A registered nurse was performing her regular duties in a secured area of a tertiary psychiatric care facility when she was physically assaulted by a patient. Several other nurses intervened and stopped the assault. The nurse sustained serious injuries.

Investigation conclusions

Cause

• Nurse was injured after exposure to a known workplace hazard. The high risk of violence from the patient had been identified and was well understood by the staff at the psychiatric care facility. When the nurse came into close proximity to the patient, she was physically assaulted while performing her normal duties.

Contributing factors

• Hazard control inappropriate for level of risk. The patient’s records and an assessment conducted at the psychiatric care facility indicated that the patient presented a high risk to staff. Previous to this incident, planned Code White procedures were used whenever workers were required to leave the secure nurse station and were exposed to the potential of further violence from the patient. (The unplanned Code White procedure is a reactive control measure, meaning that it is initated by a violent act. It is designed to provide support to nurses when a violent incident occurs at the facility, and to prevent or mitigate workers’ exposure to aggression or potential aggression from patients.) On the day of the incident, however, the planned Code White procedures were not instituted, and the nurse was permitted to work unaccompanied in close proximity to the patient as she performed her regular duties, such as dispensing medication and providing care to other patients. Without the presence of many nurses, as specified in the planned Code White procedures, the risk of violence on the part of the patient was not controlled. Once the assault began, it was stopped only after several other nurses intervened.
• Mitigation measures did not perform as expected. The nurse’s training in physical manoeuvres for dealing with a violent person was not augmented by practical experience. When the assault began, the nurse was forced to immediately adopt a defensive posture and was unable to use any of the tactics learned in the classroom. Similarly, the duress badge she wore proved to be of no benefit because the nurse’s hands were completely occupied with her self-defence, and she simply could not press the duress badge to summon help.
• Inadequate supervision. Given the patient’s past violent behaviour, high-level management at the psychiatric care facility was involved in developing and updating the patient’s care plan, and supervisory support was provided to the affected workers. After the patient had spent time in seclusion for two violent incidents, little change was made to the behaviour management strategies that staff were to follow after the patient was released from seclusion. Thus, the same hazardous situation resulting in violence by the patient was allowed to develop repeatedly. After the first instance of violence, the care plan should have been revised and supervisory oversight instituted to ensure that workers did not approach the patient unaccompanied.

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