Bedside Risk Assessment, Part 5 – Now What?

All – I have to start by apologizing for my unannounced hiatus. Life gets away from you sometimes, but I am glad to be back. In all honesty, I really did miss this time.   

This week I want to wrap up our discussion on bedside risk assessments by talking through proactive response. I have shared with you three excellent bedside risk assessment tools, and there are many more out there. We talked about how the tools worked, and in my last post we even talked a little about the who and the why. This week I want us to wrap this discussion up by talking about the ‘now what’. What I mean is, you have the tool, you use the tool, but then what do we do with the information provided by the tool. So, the patient is a high risk for violence, what is next?

There is a plethora of ideas out there on what makes for the best proactive response, but the tools I want to discuss today are: (1) behavioral agreements, (2) proactive patrolling, (3) agitation/ delirium protocols, and (4) psychiatric consultation. I have chosen these tools for their specifically proactive posture. These are not reactive tools, they are proactive tools designed to be preventative.


A proactive posture is a difficult one to take. Ultimately you are acting based on the potential for something to happen instead of because something has happened. But, once you have assessed risk you should always work to mitigate that risk. One tool that has been successful is the behavioral agreement. A behavioral agreement is a formalized version of limit setting, and limit setting is a tactic used in de-escalation to great effect when properly applied. The agreement is a one-page document that outlines, in simple language, what behavior is not acceptable. This helps to formalize the limit setting discussion. It also carries the weight of the subject’s signature, and can be used as a demonstration of their agreement in the future. The agreement also helps to document the limit setting conversation, and ensure everything that should be covered is covered.

Proactive patrolling is another key tool in violence mitigation. Knowing there is an increased risk gives security forces an edge in prevention. Consistent and constant security presence through targeted active rounding can help suppress acting out behaviors. In addition, this also helps reassure the staff serving the patient that their safety is an organizational priority. Finally, increased presence and awareness decreases response time when needed, and can help reduce the level of a potential issues by ensuring that security staff are quicker to respond.

The last tool I want to discuss is a medically sound agitation and delirium protocol as well as proactive psychiatric consultation for the patient. Despite the initial reaction of many, these are legitimate security tools used in collaboration with our clinical partners. I believe we cannot effectively address violence proactively if we are not leveraging the work of our clinical partners along with our work as security professionals. It is imperative that we are working closely with the medical providers in our institutions to build effective treatment for agitation and delirium, and also that we are pulling into the preventative conversation our psychiatric professionals as soon as practical. In both cases the effective medical treatment of the patients not only serves the welfare of the patient, but also serves the welfare of those treating the patient, providing the best-case scenario for a quality healing environment.

What tools would you use? If you knew the risk was present, how would you work collaboratively to prevent violence from occurring? Put your thoughts below, and let’s carry on the conversation. We can prevent violence together.

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