VIOLENCE RISK SCREENING AND SAFETY ALERT TOOL

DOCUMENT TYPE: FORM

Patient Label

1) Based on your screening questions (see work standard) - Does this person have a recent history of violence potentially affecting the safety of staff, patients, or visitors?

NO - go to question 2YES - Is there a Safety Alert on Cerner?

NO - Complete form and activate Cerner Safety AlertYES - Contact Health Records for chart with existing care plan

2) Is this person currently physically/verbally aggressive or threatening?NO - Continue with admission / on-going assessmentYES - Complete this form and activate Cerner Safety Alert.

Date of Application:Entered Safety Alert in Cerner: Yes No

Date of Removal:Removed Safety Alert from Cerner: Yes No

Violence Risk Safety Alert is for PATIENT/CLIENT OTHER:ACTIVATING EVENT

RISK FACTORS

□ Acquired Brain Injury □ Alcohol / Drug Intoxication / Withdrawal□ Cognitive Impairment □ Delirium/Psychosis□ Fear, Grief, Anxiety □ Hunger□ Pain □ Recent history of violence□ Sleep Deprivation □ Sensory Deficits □Other/Unknown:

STRESSORS Environmental

□ Lack of Privacy □ Multiple Caregivers□ Perceived Disrespect □ Routine

□Changes Sensory Stimulation (noise, lights, multiple tests)□ Waiting □ Other/Unknown:

STRESSORSClient perception of

Staff Approach

□ Enforcing/Authoritative □ Not Listening□ Personal Space □ Questioning□ Rushed / Fast Pace □ Sudden Approach□ Task Focused □ Unwelcome Touch □ Other/unknown:

BEHAVIOUR□ Unwelcome Touch □ Physical Strike□ Physical Threat/Acting Out □ Instrument of Harm/Weapon:□ Verbal / Written Threat □ Other/Unknown:

INTERVENTIONS

SUPPORT / INTERVENTION

□ Active Verbal De-escalation □ Distraction

□ Given Space / Left Alone / Visit Ended □ Limit Setting

□ Team Response □ Medication

□ Physical Restraint □ Security

□ Police □ Other/Unknown:

C-0506-06-60186 | PHSA 303 Published Date: 14-Jan-2020Page 1 of 2 Review Date: 14-Jan-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

VIOLENCE RISK SCREENING AND SAFETY ALERT TOOL

DOCUMENT TYPE: FORM

Patient Label

FOLLOW UP ACTIONS

ACTIVATE SAFETY ALERT

SYSTEM

□ Inform the patient/other of the Violence Risk Safety Alert activation when safe to do so. Date:

Initial:

□ Place Violence Risk Safety Alert Tool at front of chart (behind the CAUTION sheet if present)

Date: Initial:

□ Post purple visual alerts, such as:

Place a purple dot sticker on the spine of health record and Kardex (if used)

Place purple dot stickers on any requisitions (e.g. Labs, x-ray, etc.)

Place purple indicator sign on door (BCCH ED)

□ ESTABLISH A SAFETY ALERT CARE PLAN

□ Activate Safety Alert Icon in First Net (BCCH ED Only) Date Initial

□ Complete/send electronic client information screen(s) for ALERT (where applicable)

COMPLETEDBY: DESIGNATION:

Developed By C&W Violence Prevention, Workplace Health

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN23-Mar-2019;1-May-2019

C-0506-06-60186 Violence Risk Screening And Safety Alert Tool

Approved at: Perinatal Best Practice; BCCH Best Practice Committees

14-Jan-2020 “ Action: Professional Practice Associate Director added □ to form

Disclaimer This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-0506-06-60186 | PHSA 303 Published Date: 14-Jan-2020Page 2 of 2 Review Date: 14-Jan-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.