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Potential harm to both physician and patient remains a constant challenge for the neurohospitalist. Physicians can be faced with violent or threatening patients where a strategic approach can include assessing for contributing factors, as well as pharmacological and nonpharmacological measures. Inadvertent risks to physicians include exposure to body fluids and needle sticks. Precautions have advanced along with our understanding of transmissible disease. Patients can be subjected to harm. As the systems of delivery and diagnostic and treatment modailities become more complex, the opportunity for medical errors can flourish. Individual errors and system failures can result in serious adverse events or near-misses. Hospital-acquired conditions can be infectious or noninfectious and generally have a deleterious effect on outcomes, cost, and length of stay. Evolving health care policy and hospital practices aim to reduce the potential for harm.


CASE 2-1

A 65-year-old man with bipolar disorder, hypertension, hyperlipidemia, prolonged QT interval, and diabetes mellitus presented to the emergency department with headache and vision loss. He was found to have a subacute ischemic stroke. The night following admission, he became agitated and threatening toward staff. He screamed and repeatedly punched the walls. He lacked decisional capacity, and no family members could be reached. Repeated attempts by staff and the on-call physician were made to calm him, but he remained aggressive.


  • Workplace violence is a problem in many industries, but hospital workers have the highest rates of nonfatal workplace assault injuries.

  • Most are violent acts committed by patients toward staff.1,2

  • 50% of healthcare workers will be a victim of work-place violence during their careers.1

  • Nurses, mental health professionals, and security staff are at greatest risk.2

What are contributing factors to violent or threatening patients?

  • Neurological, psychiatric, and genetic disorders, and drug abuse can predispose to aggressive behavior(Table 2-1).3,4

  • Social factors can also contribute.

  • Identify contributing factors early to mitigate risk.

Table 2-1.

Predisposing Factors to Violent Behavior

What are nonpharmacological strategies to deal with violent or threatening patients?

  • Environmental elements should be controlled, such as physician and staff attitudes and patient comfort. Offering blankets or refreshments, and relative isolation in a private quiet room can be considered.1,2

  • Physicians and staff must be vigilant about their surroundings, body language, and exit locations.

    • Maintain a safe ...

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