Date of incident: September 2019
Notice of incident number: 2019165700017
Employers: Regional health authority; tertiary care hospital; security company; construction and management company (prime contractor)

Incident summary

In the middle of the night, a nurse heard sounds coming from a patient’s room and entered the room to check on him. The patient struck the nurse in the face with a dumbbell, causing her to fall to the floor. The nurse sustained serious injuries.

Investigation conclusions

Cause

• Patient concealed himself and struck nurse as she entered room. The patient concealed himself behind a curtain in his room and struck the nurse in the face with the dumbbell as she walked into the room to check on him.

Contributing factors

• Ineffective communication between wards. The patient had been in hospital for a number of days when the incident occurred. The electronic medical records (EMR) for him contained information regarding his potential for aggression and violent behaviour (AVB) and actual exhibited AVB. The nursing staff, however, appeared to rely primarily on handover notes and hardcopy patient charts, reviewing the EMR only when time permitted. (Handover notes contain patient information deemed to be important by clinical staff, but may not present all relevant patient information.) Prior to the incident, the patient exhibited AVB that triggered a Code White response. Forms required to be filled out by the Code White policy and the Alert System policy were not completed and placed in the patient’s chart and therefore were not available to the nursing staff to provide critical information regarding the patient’s potential for AVB. Nor were these forms available to the leadership team, which had access to the EMR for the patient, when it met to discuss the patient and implement control measures. The plan created by the team to manage the AVB risk posed by the patient was contrary to the care plan created when he was admitted to the ward. That earlier care plan was only uploaded to the EMR hours after the leadership team meeting. 
  
• Inadequate evaluation of risk of violence. Although a leadership team meeting was conducted as a result of concerns regarding the patient, and violence prevention procedures were in place on the ward, the degree of risk of AVB by the patient was underestimated, and the measures put in place to lessen the risk were ineffective.
• Nursing staff not adequately informed of risk of violence. As mentioned, a care plan was devised before the leadership team meeting as a recognized tool to mitigate risk to staff attending the patient. The care plan was not used because it did not appear in notes placed in the patient’s chart and because nursing staff did not consult the EMR, where the care plan did appear. An accurate and complete description of AVB exhibited by the patient and control measures employed to deal with the AVB were not discussed with the nursing staff. The decision to have a security guard posted outside the patient’s room was described as a precautionary measure, based on a perceived threat posed by the patient of potential violence outside the hospital. 
• Security staff conducted inadequate risk assessment. Security staff are not able to access certain patient information, and therefore depend on clinical staff to provide appropriate and adequate information regarding patients when a security guard is requested. The only relevant information that was passed on to the security supervisor was some detail about the perceived threat posed by the patient of potential violence outside the hospital. The security company, the company that provides management services to the hospital (the prime contractor at this multiple-employer workplace), and the regional health authority needed to collaborate to put in place a coordinated process and system to ensure that security staff asked hospital staff for (and obtained) the necessary information to enable adequate security coverage to be provided and to mitigate the risk of violence against security staff.
• Failure to adhere to violence risk assessment action plan. An action plan for reducing the risk of violence on the ward called for staff to conduct environmental scans to ensure items that could serve as weapons were appropriately stored or secured. The investigation found that in this case, no such scans were conducted on the ward. The patient demonstrated interest in the dumbbell, but the dumbbell remained accessible to him. The patient’s use of the dumbbell as a weapon in the assault aggravated the severity of the nurse’s injuries. 

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