My first day of medical residency program began with the admission of the victim of a workplace shooting. He was a security guard responding to gun shots.

The shooting started as a domestic dispute. A husband entered the workplace with a handgun, shot and killed his wife, and slightly wounded her friend in the arm as he made the attack. He wounded the guard with a glancing shot to the head before turning the gun on himself and dying in the ER, which is where the attack occurred. Yes, this was my workplace! The security guard was admitted to my own hospital.

Fortunately, he recovered quickly from the physical injury. His emotional recovery, however, was less rapid.

Millions of American workers experience workplace violence each year. According to Injury Facts, assaults are the fourth leading cause of work-related death. In 2017, assaults caused 18,400 injuries involving days away from work and 458 fatalities.

Healthcare facilities are frequent sites for interpersonal violence. The healthcare and social assistance sector experiences nearly four times as many episodes of serious workplace violence than several other large private industry sectors including manufacturing and construction. Other service providers are also vulnerable to violence. Taxi drivers, for example, face a risk of being murdered on the job more than 20 times the risk to other workers, according to the Occupational Safety and Health Administration (OSHA).

The solution to the problem is not simple—predicting attacks has proven difficult. Violent attacks may be motivated by revenge, robbery or ideology. Mental illness may or may not be a contributing factor. And while guns are often linked to violence, a determined perpetrator will likely choose an alternative weapon if a legally acquired gun is not readily available. Tackling societal violence, therefore, requires a multi-faceted approach.

Policies to better address societal violence are necessary. Policies to recognize and manage intrusion of violence from outsiders, similar to my first-day-at-the-ER story, may be easy to implement.

Regulations and procedures addressing known problems while ensuring individual rights should be considered; however, policies targeting a single common pathway to a violent act may have serious limitations. Criminals break laws and frequently find ways around barriers created to safeguard others.

Those with an intent to harm others have no regard for an employer’s or coworker’s individual rights.

In the workplace, observant employers and workers may be able to prevent violent acts by coworkers by recognizing an individual more at risk of becoming violent. The progression from the quiet guy in the next cubicle to raging killer may be insidious. Employers must become educated on the behaviors associated with a risk of future violence. They must also determine strategies to avoid amplifying the underlying thought patterns leading to violent behaviors and better mitigate the risk of violence in the workplace. Worrisome behaviors do not necessarily lead to violence; however, identifying behaviors may open doors to develop better employees.

An Employee Assistance Program (EAP) to help employees manage the everyday struggles in life are a great investment. Employers should not approach an EAP as a punishment but rather use the EAP tool to build a healthy workforce. Prevention must always be the goal in any intervention. Sharing common warning signs with employees to facilitate self-care and a supportive work environment can be an effective preventive strategy.

These behaviors have been suggested by the National Safety Council as indicators of a potential for future violent behaviors:
• Excessive use of alcohol or drugs
• Unexplained absenteeism, change in behavior or decline in job performance
• Depression, withdrawal or suicidal comments
• Resistance to changes at work or persistent complaining about unfair treatment
• Violation of company policies
• Emotional responses to criticism, mood swings
• Paranoia
The National Safety Council offers a standardized training to address workplace violence and other safety-related issues. Customized training is also available. Visit for more information.

By Richard A. Lane, MD, MPH&TM, FACPM