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UWMF POLICIES AND PROCEDURES
Subject: Patient Altercation Response Policy – Yahara
Effective Date: 12/22/15 Approved: Mike Holman, Safety Manager
Supersedes Policy Date: Revision
The purpose of this policy is to establish a quick response to a potentially life-
threatening situation and ensure the safety of all occupants by responding
uniformly in accordance with the below set of procedures.
Patient Altercation is a situation where a strong perception exists that a person
may act out violently and cause bodily injury or property damaged, as determined
by threats, abusive language or other aggressive conduct.
Panic Buttons are devices that are monitored by an alarm company. If activated
by physicians or staff, alarm monitoring will dispatch local police for response to
Person-in-Charge means a person who is responsible for making decisions and
working with the responding police to resolve the patient altercation event.
Safe areas are areas occupants can evacuate to distance themselves from the
threat and/ or lockdown and defend in place.
Strobes are devices that interface with the panic button system and will activate
whenever a panic button is tripped. In this way, nearby staff will know of an event
and can start the response. Strobes are mounted in each wing on 1st floor and
the reception space on 2nd floor.
In the event of a patient altercation, staff or providers will use panic button
devices to notify others and local police of the event. When activated, immediate
arrangements will be made identify the affected area and direct occupants to
safe areas within the clinic. The person in-charge will work with the responding
police to resolve the altercation.
1. When a panic button is tripped inside one of the provider rooms, the strobes
will activate and keypads at reception and back employee entrance will alarm.
The affected room number will display on the keypad to inform staff of event
location. If button is tripped at reception, the strobes will activate and keypad
at employee entry will alarm.
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2. Available staff will go to the keypad to confirm event location. Thereafter, the
following will occur:
Silence alarms by entering 19681 at keypad.
Overhead page “CODE BLACK (state room or location of event)”
(repeat three times). This will inform others not affected by the
event to move and assist others to a safe area.
Appoint a person in-charge
Assign someone to meet with arriving police to provide direction.
From a safe distance, assess the altercation event. If safe to
intervene, assist with resolving the event. If unsure or event is
unsafe, move to a safe area until event is resolved.
After event has been resolved, overhead page “CODE BLACK ALL
POINTS OF EMPHASIS:
1. The above security devices must be used for “Patient Altercation” situations
only. All other emergencies have different alarm systems or protocols (i.e.
Fire, Code Blue).
2. The panic button system must be reset after the event by entering 19681 at
3. The clinic and safety & security managers will coordinate periodic drills with
all staff and providers to ensure readiness for patient altercation events.
4. After the altercation, the person most involved will complete a Patient Safety
Net (PSN) report.
5. If necessary, the clinic manager will coordinate a debriefing with Human
Resources as soon as possible after the event.
Michael E. Holman, Safety & Security Manager