Date of incident: August 2013
Notice of incident number: 2013124800233
Employer: Health care facility

Incident summary
A registered nurse working in the medical unit of a regional hospital was assaulted by a patient who was involuntarily admitted under the Mental Health Act. The registered nurse sustained multiple injuries.

Investigation conclusions
Cause

• Assault by a patient on a nurse: The patient was leaving the medical unit down a stairwell. After returning to the stairwell landing, the patient assaulted the registered nurse.

Underlying safety issues

• Failure to conduct a violence risk assessment before implementing a new care model: The implementation of a new care model changed service delivery, and increased the workload. Nurses had less time to assess patients and to interact with them to pick up on subtle changes in their status and behaviour. However, contrary to the health authority's own policy, a risk assessment was not conducted to determine how the new care model might affect the safety of health care staff and their risk of injury from violence.
• Failure to identify and communicate documented violence and to use the violence alert system: Different health care professionals had documented the patient's history of violence in several areas of his charting since his admission. In fact, the potential for violence was identified upon admission in the emergency department. However, a violence alert was not added to the system at that time. Afterwards, staff did not review electronic or paper records for any history of violence, or if they did, they failed to identify the risk. Due to this failure, key requirements were not implemented that included applying a violence alert symbol to the patient's file as required by policy, identifying and assessing the risk of violence, communicating the risk of violence to staff, and implementing appropriate controls to mitigate that risk. Appropriate controls may include behavioural care plans, safe work practices, and instructing and supervising workers.

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