A Closer Look at Violence in the ED

Author Information (click to view)

Roger D. Tillotson, MD

Assistant Professor of Emergency Medicine
West Virginia University Health Sciences Center

Roger D. Tillotson, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.


Roger D. Tillotson, MD (click to view)

Roger D. Tillotson, MD

Assistant Professor of Emergency Medicine
West Virginia University Health Sciences Center

Roger D. Tillotson, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

Research shows that violence against emergency physicians remains a pervasive problem nationwide. Increased awareness and more research and training on violence prevention measures may be beneficial.

The stressful nature of an ED visit has been shown to increase the likelihood of violent acts for many reasons. Common reasons include a high frequency of pain among patients, long wait times to be seen by physicians or to receive treatment for pain, and a general overall frustration with the healthcare system. Furthermore, the patients who present to the ED are often those who have a tendency toward violence, including people who are using or seeking drugs, are under the influence of drugs or alcohol, and/ or have underlying dementia or psychosis. “All of these factors increase the possibility of violent acts occurring in the ED,” says Roger D. Tillotson, MD. “Considering the escalating trend of violence toward healthcare workers, it’s important to examine the nature of these risks so that we can develop new strategies to mitigate workplace violence.”

Intriguing New Data on ED Violence

Most ED personnel are aware that violence continues to be problematic, but the literature on the topic is scarce. In the May 2011 Journal of Emergency Medicine, Dr. Tillotson and colleagues had a study published that sought to estimate the overall incidence of violence experienced by faculty and resident physicians working in academic EDs in the United States. “Our specific goal was to estimate the proportion of physicians who had experienced at least one type of violent act while working in the ED,” adds Dr. Tillotson. “We also sought to obtain information on violence prevention strategies that have been implemented by EDs.” The analysis involved 263 emergency medicine residents and attending physicians who reported 271 different types of violence experienced in the past year.

“There is a strong concern among ED physicians that more action is needed to prevent violence in the ED.”

According to the findings, 78% of respondents experienced at least one workplace violence act within the past year (Figure 1). Workplace violence was experienced similarly between male and female emergency physicians, but was more common in EDs that had annual volumes over 60,000 patients (82% vs 67%). Verbal threats were the most common type of workplace violence reported, followed by physical assaults, outside confrontations, and stalking (Figure 2). “An alarming finding with regard to verbal threats was that about one-third of ED personnel reported frequent or very frequent occurrences of such events,” Dr. Tillotson says. “Unfortunately, it’s difficult to reliably predict which of these verbal threats will escalate to the level of physical assault against emergency physicians.”

The study also found that few ED personnel experienced a physical assault within the past year, but 68% of those who were physically assaulted believed frequently or most of the time that their assailant was intoxicated. Male upper-level residents at higher-volume EDs reported experiencing assaults more often than other respondents. Only 5% of respondents reported having experienced confrontations outside of the workplace. In comparison with other types of violent acts, the perpetrators of these confrontations were less likely to be intoxicated and were more likely to be family members of patients.

Assessing Violence Countermeasures

The majority of respondents in Dr. Tillotson’s study reported that their EDs did not have metal detectors or screen for weapons. One in 10 of all respondents reported an incident in which a weapon was brandished or used against them. Only about 25% reported that they had participated in some type of self-defense workshop, and 14% reported having participated in violence trainings or workshops. Another 24% reported incidents in the ED that resulted in changes in security policy, including increased security presence, more weapons screening, badge-protected check points, locks on ED doors, greater use of restraints, and use of metal detectors.

Interpreting Findings of Workplace Violence

Considering the high incidence of workplace violence experienced in the ED, Dr. Tillotson says more work is needed to develop violence prevention measures for ED staff. “Few ED personnel throughout the country work in settings that provide workshops on violence or self-defense training,” he says. “There is a strong concern among ED physicians that more action is needed to prevent violence in the ED. Some ED physicians feel the need for self-defense training and are going outside of their program to seek this training.”

Increasing training on violence, security presence, metal detectors, and weapons screening may help decrease the incidence of violence in EDs, says Dr. Tillotson. “However, more research is needed to demonstrate the true effect of violence prevention mechanisms on actual violent events for the long term. In the meantime, ED personnel should be aware of the incidence of these events and prepare themselves as best they can to diffuse potential violent acts whenever possible. With more research, the hope is that education and training programs in violence awareness and prevention— in addition to self-defense training—will be beneficial for ED physicians and residents to better avoid these issues in the future.”

Readings & Resources (click to view)

Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. J Emerg Med. 2011;40:565-579. Available at:

Kowalenko T, Walters B, Khare R, Compton S. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med. 2005;46:142-147.

Gates D, Ross CS, McQueen L. Violence against emergency department workers. J Emerg Med. 2006;31:331-337.

Kuhn W. Dealing with violence in the emergency department. Available at:

Greene J. Violence in the ED: no quick fixes for pervasive threat. Ann Emerg Med. 2008;52:17-19.

Grange JT, Corbett SW. Violence against emergency medical services personnel. Prehosp Emerg Care. 2002;6:186-190.

Kansagra SM, Rao SR, Sullivan AF, et al. A survey of workplace violence across 65 U.S. emergency departments. Acad Emerg Med. 2008;15:1268-1274.

Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33:676-679.

Fernandes CMB, Raboud JM, Christenson JM, et al. The effect of an education program on violence in the emergency department. Ann Emerg Med. 2002;39:47-55.

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