Threat Assessment Strategies to Mitigate Violence in Healthcare

Ongoing Case Management

If the TA team determines that a person under review poses a threat of violence to others or suicide, the team should then develop, implement, monitor and document a plan to intervene and reduce the threat.  Nolan, Randazzo and Deisinger provided the following advice to the University Risk Management and Insurance Association in 2011.  Though this information was designed for the education sector, it can easily be translated to healthcare.[85]  “The plan should be customized to best address the person of concern and situation with the resources that the team and institution have available or could access or coordinate. The goal of a threat management plan is to help move the person of concern away from thoughts and plans of violence or suicide and get assistance to address problems.”  

Threat management/case management plans can include any of the following as the situation and resources dictate:

  • Monitor the situation for further developments
  • Engage with the person of concern to de-escalate the situation
  • Involve an ally or trusted person to monitor the person of concern
  • Law enforcement intervention
  • Voluntary referral for mental health evaluation and/or treatment
  • Involuntary hospitalization for evaluation and/or treatment
  • Modification of the environment to mitigate impact of contributory factors
  • Collaborate with identified target/victim to decrease vulnerability
  • Monitor and prepare for impact of likely precipitating events

The goal of monitoring is to ensure the plan is having the intended effect and not inadvertently making the situation worse.  The plan should be monitored and modified as needed for as long as the person/situation may pose a threat. It may be necessary for the TA team to revisit cases in anticipation of future precipitating events such as key dates, personal or career setbacks or the occurrence of violent attacks elsewhere that could prompt the person to become an increased threat. The team should develop contingency plans and take necessary steps to reduce or mitigate the anticipated threats each time this occurs.[86]


Workplace violence in healthcare is a complicated issue and the situation is continuing to worsen.  Between 2013 and 2017 there was a 10% increase in the number of injuries in healthcare and social service workplaces stemming from violence.  There was a 59% increase in fatalities related to workplace violence in the healthcare sector within that same time frame.[87] Until there is a deconfliction between OSHA and CMS regulations or a stronger stance taken to develop a workplace violence standard for the healthcare industry, organizations must take it upon themselves to identify and implement viable, evidence-based solutions to manage this trend. 

TA should absolutely be considered as a component of a comprehensive workplace violence management program.  Though not applicable to all types of violence, TA is a promising tool for managing targeted threats in the healthcare setting.  The multi-disciplinary team approach encourages information sharing and provides a set process to work through what may be a frightening or unusual situation.  It addresses the issue of when to involve law enforcement or a mental health professional.  It also fosters an environment of support for employees who are in difficult personal situations, which may lead to increased reporting of potentially dangerous behavior.   

While TA is prevalent in other industries, especially education, the minimal amount of research and literature dedicated to its use in healthcare limits its application.  More research is key to evaluating this technique as a standard component for healthcare workplace violence programs in the future.  It is also essential to determining whether a healthcare-specific assessment tool is needed.  Until then, the TA process can be easily adapted to provide benefit to healthcare organizations, particularly in using the WAVR-21, SARA and DA tools, which can be used across industries.         


Sarah J. Henkel is the Director of Safety and Security at Firelands Regional Medical Center in Sandusky, Ohio.  She holds an M.S. in Safety and Emergency Management from the University of Tennessee and a B.A. in Journalism from the Ohio State University.  She is a Certified Healthcare Security Officer and Nationally Registered Paramedic.  Previously she served in the Arlington Texas Fire Department as a special event emergency planner participating in public safety planning for large events including the 2010 and 2011 World Series and Super Bowl 45.  Ms. Henkel may be reached at


[85] Jeffrey Nolan, et. al., Campus Threat Assessment and Management Teams: What Risk Managers Need to Know, (University Risk Management and Insurance Agency Journal Reprint, 2011), 111-112.

[86] Ibid., 112.

[87] Bureau of Labor Statistics (2013, 2017).


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