Pa Patient Saf Advis 2014 Sep;11(3):115-23.    
Patient-to-Patient Aggression in the Inpatient Behavioral Health Setting

Lea Anne Gardner, PhD, RN
Senior Patient Safety Analyst

Mary C. Magee, MSN, RN, CPHQ
Senior Patient Safety/Quality Analyst

Pennsylvania Patient Safety Authority

Corresponding Author
Mary C. Magee

* Correction (Pa Patient Saf Advis 2014 Dec;11[4]:179.)


Patient aggression in the inpatient behavioral health setting is a patient safety concern to patients and clinicians. Inpatient patient-to-patient aggression (47.2%, n = 538 of 1,139) was the behavioral health aggression–related event most frequently reported to the Pennsylvania Patient Safety Authority through the Pennsylvania Patient Safety Reporting System between January 1, 2012, and August 31, 2013. Circumstances in the inpatient setting can result in psychiatric patients responding in an aggressive manner. Use of aggression assessment scales forms the basis of a multidimensional assessment approach that incorporates patient-centered, staffing-centered, and environmental-centered considerations and is a strategy that can be used to identify factors placing patients at risk for aggressive behavior.


Aggression and violence occur in the inpatient behavioral healthcare setting. Estimates of the percentage of patients who are aggressive during their stay on acute psychiatric wards vary widely, with figures between 8% and 44%.1-3 Evidence indicates that between 10% and 30% of hospitalized psychiatric patients have engaged in violence prior to admission.4,5 Aggression and violence among psychiatric patients affect the other psychiatric patients, behavioral health clinicians, and staff.6,7 Research has focused on ways to predict and manage patients’ violent behavior.6,7

Age plays a role in patient aggression. Behavioral symptoms such as aggression and agitation frequently coincide with psychiatric disorders in older adults.8 Geriatric patients are often admitted with a diagnosis of dementia, and physical aggression is among the most dangerous and distressing behaviors in patients with dementia and occurs in 52% of patients with this diagnosis,9 whereas aggressive behavior in child and adolescent psychiatric patients occurs in 29% to 40% of patients during hospitalization.10 Historically, assessments have been patient-centric and have inadvertently left out what is now understood to be meaningful and contributory information.11,12

While the literature is replete with studies focusing on the individual attributes of the patient, Cutcliffe and Riahi11,12 and Duxbury13 applied a multidimensional approach (i.e., focusing on the environment, clinician, client, and behavioral healthcare system) to address inpatient behavioral health aggression and violence. Using a multidimensional approach when evaluating an aggressive encounter provides information beyond patient characteristics that recognizes the complexity of psychiatric patient interactions.11-13 For example, patient characteristics and perceptions are one facet of a social interaction, yet staff characteristics and interactions also influence the psychiatric milieu.13 In one study, patient perceptions indicated that the demeanor of staff and unit policies (e.g., patients feeling controlled by staff) were factors in the patients’ aggressive responses, while nursing staff pointed to patient characteristics as the precipitating factors.13 Additionally, an assessment strategy using a multidimensional approach addressing patient-centered considerations (including the use of aggression assessment scales), staffing-centered considerations, and environmental-centered considerations provides a proactive framework for the practitioner to identify factors that can place patients at risk for and increase the likelihood of aggressive behavior.

Researchers acknowledge that difficulties still exist in defining aggression and violence.14 For the purpose of this article, definitions of agitation, aggression, and violence are provided to establish clarity for the reader; see "Aggression-Related Definitions."

Pennsylvania Patient Safety Authority analysts examined events of aggression in behavioral health inpatient settings reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) over a 20-month period. Analysts identified patient-to-patient aggression as the predominant type (47.2%, n = 538 of 1,139 events) of aggression reported during the time period.


Authority analysts identified aggression-related reports submitted to the Authority. The analysts then queried the PA-PSRS database using the keyword search terms “abusive,” “aggressive,” “agitation,” “altercation,” “attack,” “belittle,” “belligerent,” “combative,” “control,” “hit,” “ingest,” “punch,” “scratch,” and “swallow.” Results were limited to events reported by behavioral health hospitals and acute care hospital inpatient behavioral health units from January 1, 2012, through August 31, 2013. The analysts selected this time period to ensure an adequate sample size, given that aggression events are not an established event type within PA-PSRS.

This query identified 1,139 events. Analysts categorized the events by patient age: pediatric (i.e., age 18 or younger), adult (i.e., age 19 to 64), and geriatric (i.e., age 65 or older). Additionally, the events were categorized by type of aggression: patient to patient, patient to staff, or self-inflicted (e.g., suicide). The emphasis of the analysis was to identify patterns and trends found in the narratives to identify improvement strategies rather than to capture and analyze all of the aggression-related reports submitted. As noted about similar analysis in the past, “this approach has allowed the Authority to develop meaningful strategies without worrying about whether the number of events reported or the number of situations at risk for such an event is accurate.”15

Aggression Analysis

Categories of Aggression

The Figure shows the percentages of the three types of behavioral health aggression events by age group. For the geriatric population, patient-to-staff aggression was the most common type of aggression reported, followed closely by patient-to-patient aggression. For the adult population, self-inflicted aggression was the most commonly reported type of aggression, followed closely by patient-to-patient aggression. For the pediatric population, patient-to-patient aggression was the most common type reported.

Figure. Aggression Events Reported to the Pennsylvania Patient Safety Authority from January 1, 2012, through August 31, 2013, by Age Group (N = 1,139)Figure. Aggression Events Reported to the Pennsylvania Patient Safety Authority from January 1, 2012, through August 31, 2013, b

Note: Events reported for each aggression type are not mutually exclusive; therefore, the sum of the percentages for each cohort may exceed 100. There were 487 pediatric events, 588 adult events, and 64 geriatric events reported.

It was noted that the difference between the percentages of patient-to-patient aggression and the two other forms of aggression (i.e., patient-to-staff and self-inflicted aggression) in the pediatric population was large. While the difference between the percentages of patient-to-patient aggression and patient-to-staff aggression in the geriatric population was narrow, the differences between those percentages and self-inflicted aggression were very large (36.0% and 37.5%, respectively).

Patient-to-Patient Aggression

In the patient-to-patient aggression event reports, the percentages of bodily injuries, interventions implemented to keep patients safe, and the patient’s role in the aggressive encounter (i.e., the aggressor or victim) had some similarities across the age groups (see Table 1).

Table 1. Patient-to-Patient Aggression Classification of Events Reported to the Pennsylvania Patient Safety Authority from January 1, 2012, through August 31, 2013 ​ ​ ​
Classification of Event Reports
Pediatric Events
(n = 270), No. (%)
Adult Events
(n = 238), No. (%)
Geriatric Events
(n = 30), No. (%)
Injury or Treatment* †
Head or face34 (12.6)31 (13.0)10 (33.3)
Unspecified area of bodily injuries28 (10.4)16 (6.7)1 (3.3)
Other bodily injuries26 (9.6)19 (8.0)9 (30.0)
Hands12 (4.4)8 (3.4)0 (0.0)
Diagnostic testing20 (7.4)23 (9.7)3 (10.0)
Reports without indication of injury or treatment173 (64.1)165 (69.3)10 (33.3)
Restraint use39 (14.4)17 (7.1)2 (6.7)
Medications22 (8.1)27 (11.3)2 (6.7)
Seclusion6 (2.2)4 (1.7)0 (0.0)
Reports without indication of intervention211 (78.1)200 (84.0)27 (90.0)
Patient's Role
Unspecified181 (67.0)123 (51.7)1 (3.3)
Aggressor54 (20.0)70 (29.4)11 (36.7)
Victim35 (13.0)45 (18.9)18 (60.0)

* Identification of injury was determined through analysis of the narrative, in conjunction with the harm score reported.

† The events are not mutually exclusive; therefore, the sum of the number of events may exceed the N value and the sum of the percentages may exceed 100. ​ ​ ​

 For the majority of events reported, the reporter did not state that harm occurred or provide a description of the harm in the narrative; however, when harm was indicated, injury to the head or face occurred most frequently in all three age groups: pediatric (12.6%, n = 34 of 270), adult (13.0%, n = 31 of 238), and geriatric (33.3%, n = 10 of 30). Interventions used in managing patient aggression included seclusion, restraint use, and medication use. Seclusion was the least frequently reported intervention implemented in all age groups: pediatric (2.2%, n = 6 of 270), adult (1.7%, n = 4 of 238), and geriatric (0.0%, n = 0 of 30).

Identification of the patient as the aggressor rather than the victim had a similar pattern (i.e., nearly twice as many event reports) in the pediatric (20.0% aggressor, 13.0% victim) and adult populations (29.4% aggressor, 18.9% victim). In the geriatric population, the distribution between identification of the aggressor and victim in the event narratives was inverse to the pediatric and adult populations (36.7% aggressor, 60.0% victim). There were several events in which the aggressor and victim from the same event were both reported through PA-PSRS as separate events.

Assessment of Patient-to-Patient Aggression

Several event reports identified circumstances external to the patient that contributed to the aggression event. Following are some examples:

A patient became agitated at another patient. This patient placed a hand on the other patient’s hand to stop [her from] clapping her hands. When the patient did not stop, she became increasingly agitated, and the other patient [cursed] and hit the patient in the face.

Patient reports she was in the hallway obtaining towels for a shower and a male patient grabbed her buttocks. Patient states she would have hit the other patient had he been a woman.

Agitated patient punched [another] patient in the face several times. [The patient] was angry [after] asking for his glasses case for an hour; nothing pleased him. Several attempts were made to calm the patient, [who] started screaming, [which] escalated, and [the patient] just ran over to another patient in the hall and started punching [the other patient].

Studies have demonstrated a proactive approach to occurrences of patient aggression and information about whether aggression can be anticipated and/or avoided. Interviews were held with Pennsylvania healthcare representatives from two different facilities, a facility leader and a manager, to identify whether proactive approaches are in use. The interviews provided a perspective on the topic of patient aggression from the viewpoint of those who are involved daily with patients and staff. While there is no one approach identified to proactively predict an aggressive situation, a multidimensional assessment strategy has shown to be successful in both the literature and in practice.

Duxbury described three models of variables and factors that contribute to aggression:13

  1. The internal model is patient-focused and includes variables such as diagnosis, history of aggression or violence, and other risk factors such as substance abuse.
  2. The external model focuses on environmental factors such as size and layout of the unit, locked versus unlocked unit, staffing considerations, and staff-patient interaction.
  3. The situational model focuses on multiple variations in interactions between both internal model and external model factors.

Cutcliffe and Riahi describe phenomena that point to a “systematic model of aggression/violence in behavioral healthcare”:11,12

  • Environmental-related phenomena include structure or layout of the unit, personal space needs, noise level, and ambiance.
  • Client-related phenomena include demographics, diagnosis, emotional state, previous responses to unmet needs, and underdeveloped or impaired self-control skills.
  • Behavioral healthcare system–related phenomena include hospital or unit policies, unit rules, overarching behavioral health policy, and societal views or attitudes toward patients.
  • Clinician-related phenomena include degree of communication or interpersonal skills, attitudes toward aggression, degree of de-escalation and defusion skills, and engagement in clinical supervision.

A multidimensional aggression assessment approach is a strategy that can be used to identify factors that can place patients at risk for and increase the likelihood of aggressive behavior. When performing an assessment, it is important to consider what factors to assess, when to perform the assessment, and which assessment scale to use.

Patient-Centered Considerations

Patient-centered assessments focus on what can be learned from and about the patient and include items such as a thorough medical and nursing history that incorporates the patient’s social history (e.g., substance use, history of violent behavior, history of being abused, history of agitation).6,16,17 In a number of studies, patient assessment played a role in identifying traits, characteristics, and risk factors of patients prone to exhibiting aggressive behavior.18-22

Assessing a patient’s propensity for aggression can also include the use of an aggression risk assessment scale. Aggression scales have the benefit of evaluating patient behaviors and traits using a quantifiable system to calculate a number that is used to determine the patient’s risk for aggression or document observations of actual aggression episodes. Scales that are predictive in nature are designed for use in patient assessment before the aggression episode occurs, while nonpredictive scales are designed to measure the aggressive episode.

Assessment tools and scales discussed in the literature focus on patient information and characteristics. The analysts focused on aggression scales intended for use with psychiatric inpatients. Table 2 identifies aggression scales found in the literature, which population they have been used to evaluate, and the predictive trait of the scale.

Table 2. Agitation and Aggression Assessment Scales for Use in Inpatient Psychiatric Settings ​ ​
Scale Description Population Addressed
Staff Observation Aggression Scale1An instrument used to assess the degree and frequency of violent and assaultive acts by inpatients.The study focused on psychiatric and psychogeriatric inpatients.
Staff Observation Aggression Scale–Revised (SOAS-R)2,3The SOAS-R includes revised severity scores and adds options to record autoaggressive behavior (i.e., self-destructive acts), definition of aggression, and seclusion and physical restraint as possible measures for stopping aggression. The 1999 study focused on adult inpatients.
The 2002 study focused on inpatients (age not identified).
Overt Aggression Scale4-6An instrument used to assess four types of aggression: verbal, physical aggression to objects, physical aggression to self, and physical aggression to others. The instrument also measures interventions used to address aggressive acts. The 1986 study focused on inpatient adults and children at a psychiatric hospital.
The 1991 study focused on inpatients at two psychiatric centers.
The 1996 study focused on inpatient children at an inpatient psychiatric unit.
Social Dysfunction and Aggression Scale7Measures aggressive behavior other than obvious violence and assaults (i.e., it covers the total range of mild, moderate, and severe aggression).The study focused on psychiatric inpatients
(age not identified).
Rating Scale for Aggressive Behavior in the Elderly8,9Measures aggressive behavior in the elderly, ranging from simply being uncooperative or resisting help to actual physical violence. The 1992 study focused on psychogeriatric patients.
The 1998 study focused on psychogeriatric patients.
Brøset Violence Checklist10Assesses confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects as either present or absent. A checklist resulting in a score useful in predicting violence within the next 24-hour period.This study mainly focused on adult psychiatric inpatients, with the following acknowledgments: 2 patients were less than 20 years old, and 26 patients were greater than 50 years old.
Brief Rating of Aggression by Children and Adolescents11Assesses the risk of aggressive behavior of inpatients. A predictive scale useful in predicting aggression during the first six days of admission.This study focused on children and adolescent psychiatric inpatients; however, the location of scale administration was the emergency department.
Dynamic Appraisal of Situational Aggression12Assesses the risk of imminent aggression. A predictive scale useful in predicting aggression over the subsequent 24 hours and for the next shift.This study focused on non–forensic psychiatric inpatients (age not identified).


1. Palmstierna T, Wistedt B. Staff observation aggression scale; SOAS: presentation and evaluation. ActaPsychiatrScand 1987;76(6):657-63.

2. Nijman H, Muris P, Merckelbach H, et al. The Staff Observation Aggression Scale–Revised. Aggress Behav 1999;25:197-209.

3. Nijman H, Palmstierna T. Measuring aggression with the Staff Observation Aggression Scale–Revised. Acta Psychiatr Scand Suppl 2002;(412):101-2.

4. Yudofsky SC, Silver JM, Jackson W, et al. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry 1986 Jan;143(1):35-9.

5. Silver JM, Yudofsky SC. The Overt Aggression Scale: overview and guiding principles. J Neuropsychiatry Clin Neurosci 1991 Spring;3(2):S22-9.

6. Kafantaris V, Lee DO, Magee H, et al. Assessment of children with the Overt Aggression Scale. J Neuropsychiatry Clin Neurosci 1996 Spring;8(2):186-93.

7. Wistedt B, Rasmussen A, Pedersen L, et al. The development of an observer-scale for measuring social dysfunction and aggression. Pharmacopsychiatry 1990 Nov;23(6):249-52.

8. Patel V, Hope RA. A rating scale for aggressive behaviour in the elderly--the RAGE. Psychol Med 1992 Feb;22(1):211-21.

9. Shah A, Evans H, Parkash N. Evaluation of three aggression/agitation behavior scales for use on an acute admission and assessment psychogeriatric ward. Int J Geriatr Psychiatry 1998 Jun;13(6):415-20.

10. Almvik R, Woods P, Rasmussen K. The Brøset Violence Checklist: sensitivity, specificity, and interrater reliability. J Interpers Violence 2000 Dec;15(12):1284-96.

11. Barzman DH, Brackenbury L, Sonnier L, et al. Brief Rating of Aggression by Children and Adolescents (BRACHA): development of a tool for assessing risk of inpatients' aggressive behavior. J Am Acad Psychiatry Law 2011;39(2):170-9.

12. Griffith JJ, Daffern M, Godber T. Examination of the predictive validity of the Dynamic Appraisal of Situational Aggression in two mental health units. Int J Ment Health Nurs 2013 Dec;22(6):485-92. ​ ​


As an exemplar of a predictive trait scale, an interview was conducted with Drew Barzman, MD, who discussed his studies of the Brief Rating of Aggression by Children and Adolescents (BRACHA) scale and noted that the BRACHA scale is predictive of aggressive behavior. His study from 2011 evaluated the BRACHA version 0.8 in assessing the risk of aggressive behavior only in inpatient children and adolescents. The scale was administered by social workers in the emergency department, and the outcome of aggression was assessed on the inpatient unit. The majority of the scale items predicted inpatient aggression during the first six days of the inpatient admission; specifically, the study findings showed predictability of aggression in that “all BRACHA items relating to interpersonal violence or hostility were strong predictors of in-hospital aggression, as was a history of property destruction.”10

The behavioral health community recognizes the need to improve assessment, identification, and treatment of aggression. In 2010, the American Association for Emergency Psychiatry embarked on Project BETA (Best practices in Evaluation and Treatment of Agitation) to address the need for quality guidelines for the treatment of agitation, a precursor to aggressive behavior.17 While the assessment and treatment of the agitated psychiatric patient in the emergency setting is beyond the scope of this article, emergency situations may occur at any time in any setting. Symptoms of agitation may be caused by a variety of etiologies both medical and psychiatric.23 Best practices for the assessment of the agitated patient include ruling out an underlying medical condition, performing a psychiatric evaluation that includes visual observation, and paying careful attention to the patient’s verbal and nonverbal interactions (i.e., watching for cues or signaling behavior such as pacing, raised voice, or threats).17,24

According to an interview with a manager at a Pennsylvania healthcare facility, staff are expected to do rounds and observe patients every 15 minutes to identify potential changes in any patient’s behavior. The rounds conducted are formal, and the location of the patient, their behavior, and who observed them are documented every 15 minutes. Patient assessments are performed a number of times: initially on arrival to the facility (e.g., emergency crisis center, emergency department), prior to transport or upon arrival to the inpatient setting, and whenever a change in the patient’s condition is warranted. A social worker meets with the patient in the crisis center to determine if they meet criteria for inpatient admission. Staff from the inpatient unit meet the patient, read them the patient’s bill of rights, escort them to the unit, perform a contraband search, and obtain a nursing admission assessment, which includes medical history, family support, religion, abuse history, past violent behavior on the patient’s part, sexual orientation, drug and alcohol use, contact person, and food-related issues. Nursing staff perform a suicide assessment as soon as the patient comes onto the unit to determine if the patient will require one-to-one continuous observation. A medical physician performs the medical workup and evaluation, and a psychiatrist performs the psychiatric evaluation. Based on the results of these assessments, staff identify education needs (dietary and/or physical therapy), which also includes ascertaining what works best for the patient during agitated states, such as listening to music, exercising, or crafts.

One experimental study employed an assessment approach that included the use of six different assessment scales applied routinely to each patient of an experimental group. Two scales were used daily and the rest were used weekly; they were collectively called the Crisis Monitor, defined as a structured short-term risk assessment strategy.25 The use of multiple assessment scales together can be thought of as an assessment bundle. The study’s authors predicted a reduction in aggression incidents and seclusion rates. The results showed a significant decrease in the number of aggression incidents and number of hours spent in seclusion, which suggests that a “structured short-term risk assessment incorporated into routine care planning” led to these significant reductions.21

Patient assessment is an integral component of providing safe behavioral healthcare, but it is only one aspect of a comprehensive assessment strategy. In a study by Griffith et al. (2013), the use of the Dynamic Appraisal of Situational Aggression–IV instrument “predicted aggression significantly better than unaided clinical risk ratings” for a limited time period in a nonforensic inpatient setting.21

Staffing-Centered Considerations

Patients identify staff interactions and restrictive regimens as a large factor contributing to aggression.13 Also called “situational risk factors,” the quality of the initial interaction or therapeutic alliance between the therapist and the patient has been identified as a predictor of violent behavior. One study in which the authors used the Brief Psychiatric Rating Scale and the Overt Aggression Scale as measures demonstrated that patients who had poorer therapeutic alliance at the time of admission were significantly more likely to display violent behavior during hospitalization.26 This study suggests the importance of establishing a positive patient-therapist alliance as a strategy to limit aggression. In Cornaggia et al.’s (2011) systematic review of a decade’s worth of published articles, harmony among staff (i.e., a good working climate) appears to be more useful in aggression prevention than other strategies of staffing such as more male nurses.27 Some examples are good communication techniques, staff being available to patients, and providing patient education.

In an interview with one Pennsylvania healthcare facility manager, the manager explained how the staff “takes time to get to know the patient” and finds out from the patient what interests they have and what specifically works for them when they are becoming agitated. Specifically, this manager stated, “When you see someone starting to get agitated like walking around, pacing, or yelling, staff intervenes right away. The nurses will walk and talk to the patient, a talking technique. They ask the patient what medications have helped them in the past or for instances like this. The nurses assess what helps the patient and ask, ‘What do you do to calm yourself down?’ This is very specific to the patient.”

The skill set and competency of staff contributes to a positive unit climate. De-escalation techniques are valuable skills to possess and are frequently used in behavioral health to prevent aggression and violence.22,28 Specific factors to consider include having appropriate staff who possess favorable characteristics such as openness, honesty, and genuine concern for the patient; adequate training of staff; availability of staff; and space to de-escalate.

In an interview with one Pennsylvania healthcare facility manager, the manager noted that the facility’s staff receive formal certified training annually in the management of the aggressive/assaultive patient and that staff have to demonstrate back to the trainer the skills they have learned.

Environmental-Centered Considerations

When assessing for aggression, consider the factors of the environment in which the patient is being cared for, the staff who work there, and the behavioral health system itself. In an interview with a Pennsylvania healthcare facility leader, the leader emphasized the significance of environment and proper placement of patients on units that fit the needs of both the patient and the unit when managing aggression. Regular observation and monitoring are basic activities to start with. An environmental-centered assessment and evaluation starts with identifying patients and situations in which the milieu within a behavioral setting starts to move away from a comfortable therapeutic environment to an environment where tension becomes more noticeable.

A study by Hage et al. (2009) identified environmental risk factors specific to the adolescent population. Those factors included negative family climate, violent or antisocial peer groups or neighborhoods, negative or hostile school factors, and social disadvantages (e.g., economic status, teen pregnancy, single-parent family, low educational achievement) and were found to be linked to a likelihood of aggressive and violent behavior.20

Environmental-related considerations include the structure or layout of the unit, personal space needs, color and ambiance of the unit, locked doors, noise level, overstimulation, degree of privacy, and other clients.11 Behavioral healthcare system–related considerations, such as hospital and unit policies, unit rules, societal views or attitudes toward the patient, and culture and customs of the healthcare organization, also play a role when assessing the patient’s environment.13

Based on the studies reviewed by Cutcliffe and Riahi, there appears to be a relationship between environment-related (i.e., health system) factors and the likelihood of aggression.12 In a Fagan-Pryor et al. study, patients who had observed patient-to-patient aggression identified some of the causes as bullying, patients not liking each other, use of abrasive words, and wanting another patient’s material possessions.29

In an interview with the manager, the philosophy of the unit is to have a very structured program, keep patients busy, and not allow for much “downtime.” Most of their inpatient rooms are private, and the manager feels this helps decrease aggression because patients do not have to be in the same room with one another and do not bother each other. Private rooms also give agitated or upset patients a private place to go to cool off.

Multidimensional Aggression Assessment

To identify factors that may place patients at risk for aggressive behavior, a multidimensional aggression assessment approach may be used that incorporates patient, staffing, and environmental-centered considerations, such as the following:

  • Patient-centered:
    • Conduct a thorough medical and nursing history, which includes the social history.22
    • Incorporate aggression assessment scales.6,7,18,21,23,25,26
    • Rule out an underlying medical condition.17
    • Perform a psychiatric evaluation, including visual observation.17
    • Observe for cues or signaling behavior.21
  • Staffing-centered:
    • Establish a positive initial alliance between the therapist and staff.26
    • Incorporate an approach by staff that is respectful, noncontrolling, unprovocative, and noncoercive.12,13
    • Use training, skills, and competencies that include de-escalation.22,28
    • Ensure that the staff is harmonious and staff members possess good interpersonal skills.22,30
  • Environmental-related:
    • Ensure availability of diversionary activities for the patient.11,20,22
    • Create a physical layout that avoids overcrowding and permits freedom to move around.12,30
    • Apply and communicate unit rules in a consistent manner.13
    • Establish an environment that minimizes aversive stimuli, such as noise.12
    • Maintain a smaller inpatient census and shorter length of stay.31
    • Create a physical layout that allows for personal space and privacy.12


In Pennsylvania, facilities submit three types of reports: (1) Incidents, which are submitted only to the Authority; (2) Serious Events, which are submitted to both the Authority and to the Department of Health (DOH); and (3) Infrastructure Failures, which are submitted only to DOH.32 Facilities may report aggression as an Infrastructure Failure; therefore, the quantity of events discussed in this article may not represent the full scope of patient aggression events in Pennsylvania. According to the Medical Care Availability and Reduction of Error Act, an Infrastructure Failure is “an undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety.”33

Furthermore, some of the event reports have a “canned” or the same submission narrative, which limits insights into understanding circumstances that factored into the aggression event. Narrative keyword search terms such as “throw,” “bite,” or “spit” were considered in identifying aggression event reports but were deemed unreliable, as these words are in many instances a substring of another word that would lead to the identification of non-aggression-related event reports.

For example, the word “bite” is a substring of the word “exhibited,”and the word “spit” is substring of the word “despite.” These keywords also can be used in a nonaggressive context (e.g., throw out a tissue, flea bites), thereby confounding the identification of aggression-related event reports.


Aggression in the inpatient behavioral health setting poses a patient safety concern to patients and behavioral health clinicians. Analysis revealed that reports of patient aggression were categorized as patient to patient, patient to staff, and self-inflicted. Inpatient patient-to-patient aggression was the behavioral health aggression–related event most frequently reported to the Authority through PA-PSRS from January 1, 2012, through August 31, 2013.

Patient assessment is the first step in understanding the complexities of a psychiatric patient’s experience. Historically, assessments for aggression have been patient-centric and have inadvertently left out what is now understood to be meaningful and contributory information. While there may be no single approach to head off an aggressive situation, establishing a multidimensional assessment approach that incorporates patient-centered, staffing-centered, and environmental-centered considerations and using assessment scales are strategies that can help identify factors that can place patients at risk for aggressive behavior.


Alexandra Gurko, MSN, RN, Bayada Pediatrics Home Health Care, and Christine McIntyre, BSN, RN, CRRN, WCC, Bryn Mawr Rehabilitation Hospital–Mainline Health, contributed to the data analysis and literature review for this article.


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  32. Pennsylvania Patient Safety Authority. 2013 annual report [online]. 2014 Apr 30 [cited 2014 Apr 30].
  33. 2002 Pa. Laws 154, No. 13. Medical Care Availability and Reduction of Error (Mcare) Act.

Supplemental Material

Aggression-Related Definitions

Aggression: “A forceful behavior, action, or attitude that is expressed physically, verbally, or symbolically. It may arise from innate drives or occur as a defense mechanism, often resulting from a threatened ego. It is manifested by either constructive or destructive acts directed toward oneself or against others.”

Agitation: “A state of chronic restlessness and increased psychomotor activity generally observed as an expression of emotional tension and characterized by purposeless, restless activity. Pacing, talking, crying, and laughing sometimes are characteristic and may serve to release nervous tension associated with anxiety, fear, or other mental stress.”

Violence: “Great force, either physical or emotional, usually exerted to damage or otherwise abuse something or someone.”

Source: Mosby’s Medical Dictionary. 8th ed. Philadelphia: Elsevier; 2009: s.vv. “aggression,” “agitation,” “violence.”


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