California Adopts Strongest Standard for Workplace Violence Prevention for Healthcare Employees

Studies show that health care workers are at a significantly higher risk of workplace violence than the average worker in other industries.   The Federal Occupational Safety and Health Administration (OSHA), reports from 2002-2013, the rate of serious workplace violence incidents (who require days off for an injured worker to recuperate) was more than four times greater in the health care industry than in the private industry on average.

In October of 2016, the California Occupational Safety and Health Standards Board (Standards Board) unanimously accepted a new General Industry Order entitled “Workplace Prevention in Health Care”.  The Office of Administrative Law approved the standard in December of 2016, and is codified at Section 3342 of Title 8 of the California Code of Regulations.   The rule is far more extensive than the Federal OSHA’s guidelines for the prevention of workplace violence in health care settings.

Beginning April 1, 2017 all employers in California operating in the following health care areas will be required to comply with Section 3342, the “Workplace Prevention in Health Care” rule:

  • Health Care facilities
  • Home Health Care Programs
  • Drug Treatment Programs
  • Emergency Medical Services
  • Outpatient Medical Services to Correctional and Detention Settings

The Standards Board Broadly Defines “Workplace Violence”

“Workplace violence” is defined as any act of violence or threat of violence that occurs at the worksite.   The term workplace violence does not include lawful acts of self-defense or defense of others.  Workplace violence includes the following:

  1. The threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury;
  2. An incident involving the threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regarding of whether the employee sustains an injury:
  3. Four workplace violence types
    1. “Type 1 violence” means workplace violence is committed by a person who has no legitimate business at the worksite, and includes violent acts by anyone who enters the workplace with the intent to commit a crime.
    2. “Type 2 violence” means workplace violence directed at employees by customers, clients, patients, students, inmate, or visitors or other individuals accompanying a patient.
    3. “Type 3 violence” means workplace violence against an employee by a present or former employee, manager or supervisor.
    4. “Type 4 violence” means workplace violence committed in the workplace by someone who does not work there, but has or is known to have had a personal relationship with an employee.

Workplace Violence Prevention Plan

Healthcare employers covered by the Standards Board are now required to establish, implement and maintain an effective workplace violence prevention plan, which must be in effect at all time and in every service, unit or operation.     The Prevention Plan must be in writing, it must be specific to the hazards and corrective measures for the unit, service, or operation, and be available to all employees.  The written Prevention Plan may be incorporated into the employer’s written Injury and Illness Prevention Plan or maintained as a separate document.

The Workplace Violence Prevention Plan must include the following

  • Names and job titles of the persons responsible for implementing the Prevention Plan;
  • Effective procedures to obtain the active involvement of employees and their representatives in developing, implementing, and reviewing the Prevention Plan, including their participation in identifying, evaluating, and correcting workplace violence hazards, designing and implanting training and reporting and investigating workplace violence incidents;
  • Methods the employer will use to coordinate implantation of the Prevention Plan with other employers whose employees work in the same health care facility, service, or operation, to ensure that those employers and employees understand their respective roles as provided in the Prevention Plan;
  • Effective procedures for obtaining assistance from appropriate law enforcement agencies during all work shifts;
  • Effective procedures for the employer to accept and respond to reports of workplace violence and to prohibit retaliation against an employee who makes a report;
  • Procedures to ensure that supervisory and non-supervisory employees comply with the Prevention Plan;
  • Procedures to communicate with employees with employees regarding all workplace violence matters;
  • Procedures to develop and provide training to employees that addresses workplace violence risks that employees are reasonably anticipated to come across on the job;
  • Assessment procedures to identify and evaluate environmental and community-based risk factors for each facility, unit, service or operation, which must include a review of all workplace violence incidents that has occurred in the facility service, or operation during the previous year, whether or not an injury occurred;
  • Procedures to correct workplace violence hazards in a timely manner;
  • Procedures to recognize and evaluate patient-specific risk factors and assess visitors or other persons who are not employees;
  • Procedures for post-incident response and investigation.

The Standards Board describes in immense detail the procedures that must be addressed within each of these topics.

Each year, the employer is required to review the effectiveness of the Prevention Plan and make any corrections.   The yearly review must include employees and their representatives and address the employees’ respective work areas, services and operations.  The Standards Board sets out numerous additional items the employer must consider when reviewing the Prevention Plan, including staffing, adequacy of security systems and job design and equipment.

Violent Incident Log

All Healthcare employers are required to record in a ‘violent incident log” every incident, post-incident response, and workplace violence injury investigation with descriptive details.  The employer must review the log as part of its yearly review of the Prevention Plan.

The log must contain, at a minimum, the following items:

  • The date, time, specific location, and department of incident;
  • A detailed description of the incident;
  • A classification of who committed the violence;
  • A classification of circumstances at the time of the incident;
  • The type of incident;
  • The consequences of the incident;
  • Contract and other information about the program completing the log.

As with the Prevention Plan, the Standards Board describes in specific detail the information that must be included for each item.


The Standards Board requires healthcare employers to provide training to employees created to address the workplace violence risks that employees are reasonably probable to encounter in their jobs.   The employer must have an effective procedure for obtaining the active involvement of employees and their representatives in creating training curriculum and training materials, participating in training programs, and reviewing and revising the training programs.

The Standards Board requires that training be conducted at various times, including;

  • When the Prevention Plan is first established and when an employee is hired or newly assigned to perform duties for which the training was not previously provided;
  • When there is new equipment or work practices are introduced;
  • When a new or previously unrecognized workplace violence hazard has been identified.

The Standards Board requires the initial training to address the workplace violence hazards identified in the facility, unit, service or operation, and the corrective actions the employer has implanted.  The initial training also must include:

  • An explanation of the employer’s Prevention Plan, including the employer’s hazard identification and evaluation procedures, general and personal safety measures the employer has created, how the employee may communicate concerns about workplace violence without fear of retaliation, how the employer will address workplace violence incidents, and how the employee can participate in reviewing and revising the Prevention Plan;
  • How to recognize the potential for violence, factors contributing to the escalation of violence and how to neutralize them, and when and how to find assistance to prevent or respond to violence;
  • Strategies to avoid physical harm;
  • How to distinguish alerts, alarms, or other warnings about emergency situations such as mass casualty threats and how to use identified escape routes or locations for sheltering, as applicable;
  • The roll of private security personnel, if any;
  • How to report violent incidents to law enforcement;
  • Any resources available to employees for coping with incidents of violence, including, but not limited to serious incident stress debriefing or employee assistance programs;
  • An opportunity for interactive questions and answers with a person knowledgeable about the employer’s workplace violence prevention plan.

Yearly refresher training also is required for employees performing patient contact activities including their supervisors.

Employees that are assigned to respond to alarms or other notifications of violent incidents or whose assignments involve confronting or controlling persons who exhibit aggressive or violent behavior must be given additional training on numerous topics prior to their initial assignment and at least yearly thereafter, including strategies to prevent physical harm, aggression violence predicting factors and characteristics if aggressive and violent patients and victims.

Reporting Requirements for Certain Hospitals

The Standards Board requires general acute care hospitals, acute psychiatric hospitals, and special hospitals to report Cal/OSHA any incident involving either of the following:

  • The use of physical force against an employee by a patient or person accompanying a patient that results in, or has a likelihood of resulting in, injury, psychological stress or trauma, regardless if the employee sustains an injury (as defined in the Cal/OSHA’s regulations requiring the reporting of other types of injuries or illness).
  • Any incident involving the use of a firearm or other dangerous weapon, regardless if an employee sustains an injury.

All the reports must be reported within 72 hours, except the report must be made within 24 hours if the incident:

  • Results in a fatality or an injury that requires inpatient hospitalization at a minimum of 24 hours for other than medical observation or if an employee suffers a loss of a limb or sustains any serious degree of permanent disfigurement;
  • Involves the use of a firearm or other dangerous weapon;
  • Presents a critical or emergent threat to the welfare, health, or safety of hospital personnel, meaning that the hospital personnel are exposed to a realistic possibility of death or serious physical harm.

The Cal/OSHA will develop an online system for employers to report the information.   The reports do not alleviate the healthcare employer from making reports that may be required by other Cal/OSHA regulations.   Employers can expect that these reports will result in a considerable number of new non-formal and on-site inspections.


The Standards Board will require healthcare employers to retain various records, including records of workplace violence hazard identification, evaluation, and correction, training records of violent incidents.   All records must be made available to employees and their representatives as well as Cal/OSHA, upon any request.