Date of incident: October 2022
Notice of incident number: 2022189760012
Employers: Regional health authority; security company

Incident summary
In the middle of the night, a patient in a medical-surgical unit in a hospital came out of his room with his walker and wearing street clothes. A nurse approached the patient and attempted to place a device on his wrist that would alert the nurses if he left the unit. The patient told her he would stab her and then stabbed her with a pocketknife. The patient walked 6 to 10 metres down the hall and stabbed another nurse. While the patient continued to attempt to stab the second nurse, nurses grabbed his arms and he dropped the pocketknife. Two nurses sustained injuries.

Investigation conclusions

Cause

• Patient stabbed nurses with concealed pocketknife. The patient was attempting to leave the unit wearing his own clothing when he stabbed two nurses with a pocketknife he had concealed in his clothing.

Contributing factors

• Failure to adequately communicate patient information. The workers in the medical-surgical unit were not sufficiently advised of the patient’s behaviour in another unit of the hospital. No critical care indicator (used to flag patients who pose a possible safety risk to workers) was entered into the electronic database for patient information, and a behavioural safety care plan, behaviour checklist, and risk profile form were not completed for the patient. Workers rely on the transfer forms, handover reports, visual indicators, critical care indicators, and risk profile forms to accurately identify risk. While detailed information on the patient’s previous history was handwritten in the nursing notes of his chart, it was not feasible for each worker to read through these notes before their shift. If the critical care indicator and the risk profile forms had been completed for the patient while he was in the previous unit, workers would have been provided with accurate information on the risk of violence and a plan to mitigate those risks.
• Lack of patient search policy. At the time of the incident, the health authority did not have a patient search policy. Workers believed they were not allowed to search a patient or their belongings. A patient search policy had been created but had not been put into effect at the time of the incident. Had the draft patient search policy been in place and workers aware of it, workers might have been able to reduce the seriousness of the incident. The policy also would have let workers know that the patient’s belongings could have been searched on reasonable grounds, which would have allowed for the possibility of locating the pocketknife prior to the incident.
• Failure to address deficiencies in previous violence risk assessment. A violence risk assessment completed in 2015 was adequate for the time period in which it was conducted; however, ongoing monitoring and implementation was not sufficient, particularly in addressing worker training. The manager of the unit was responsible for ensuring workers were aware of policies and procedures and were completing required violence prevention training. The health authority conducted inspections to assess the effectiveness of the violence risk assessment action items; however, the inspections failed to address and recognize several issues later discovered by an audit that occurred after the incident.
• Inadequate training on safe work procedures. Workers were not aware of some important policies, including regarding directing the security guards who responded to the incident, and no one called 911 during the incident as required. Workers on the medical-surgical unit take the Provincial Violence Prevention Curriculum once and do not require a refresher. Workers who have taken advanced team response violence prevention training are required to complete an annual refresher, but some of the workers on the unit had not done so. Policies and procedures are provided to workers during orientation, but there is no tracking in place to ensure those items are reviewed and no requirement for workers to have ongoing refreshers. At the time of the incident, training for the violence prevention program was not sufficient. The risk assessment identified this issue in 2015 and it had not been resolved.
• Inadequate supervision. Unlike other supervisory roles on the unit, charge nurses perform supervisory duties in addition to carrying a full patient load, and they are responsible for ensuring that the health authority’s policies and procedures are followed. However, the health authority had not provided all charge nurses with the training necessary to fulfill their role as supervisors. Having an adequately trained supervisor during a night shift is essential given the limited availability of other supervisory roles that are typically present during day shifts.

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