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UWMF POLICIES AND PROCEDURES
Subject: Patient Altercation Response Policy – Behavioral Health & Recovery
Effective Date: 11/9/15 Approved: Mike Holman, Safety Manager
Supersedes Policy Date: 8/8/13 Revision #1
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
when a panic button is tripped inside the affected room. Additionally, strobes in
the break room, copy room and reception area will activate when a panic button
In the event of a patient altercation, psychiatry 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 suite. The provider in-charge will work with the
responding police to resolve the altercation.
1. When a panic button is tripped, the keypads will alarm and affected room
strobe will activate to alert staff of an event location. NOTE: there are five
keypad locations throughout the suite.
2. Staff and providers not affected by the event will go to the nearest keypad to
confirm event location. Those with patients will then direct them to a safe area
within the suite. Those without patients will respond in the following way:
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Meet at the front desk keypad to confirm event location; thereafter,
silence alarms. Alarms can be silenced by pressing 1,2,3,4 to
acknowledge alarm, 1,2,3,4 to silence it and 1,2,3,4 to clear it.
NOTE: If event is at front desk, responding staff will meet at the
back entrance keypad.
Announce “CODE BLACK 4th floor” (repeat three times) in an all
building page through the clinic phone system to alert others who
may be in closed-door meetings.
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, seek shelter in a safe area until event is resolved.
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 program director and safety & security manager will coordinate annual
drills with all staff and providers to ensure readiness for patient altercation
3. After the altercation, the person most involved will complete a Patient Safety
Net (PSN) report.
4. The program director and safety & security manager will coordinate a
debriefing with Human Resources as soon as possible after the event.
5. If panic button system fails to clear/ alarms will not reset, notify the Program
Director. The system inside the IT closet can be unplugged (will need Phillips
head screw driver). The red wires in each of the three panels will also need to
be disconnected from the back up batteries. Vendor will need to be notified
Michael E. Holman, Safety & Security Manager