A survey discovered that more than half of emergency nurses had been spit on, pushed, scratched and verbally assaulted on the job. One in four of the nearly 3,500 emergency room nurses reported being assaulted more than 20 times in the past three years, according to the Emergency Nurses Association. And the U.S. Occupational Safety and Health Administration estimates there are 2,600 non-fatal assaults on hospital staff each year.

Emergency department personnel report that in the past violence was from people with dementia or mental health problems or who were under the influence. More recently violence comes from angry people. And, often, violence begets violence. Emergency departments now often face situations which include substance abuse, psychiatric, trauma, assaults, gunshot wounds, and stabbings related to gang violence.

The Joint Commission, formerly the Joint Commission for Accreditation of Hospitals, which certifies more than 18,000 healthcare organizations and programs, has a database indicating that, especially in urban settings, a gang war is brought from the street into the emergency department. The Joint Commission also has publicly stated that hospital violence is “extremely underreported.”

Some operations have installed metal detectors at ED entrances. For example, Detroit’s Henry Ford Hospital found 33 handguns, 1,324 knives and 97 chemical sprays in just the first half year of use of screening.

Domestic problems also end in violence in a healthcare setting. For instance, Memphis, Tenn., firefighter Frank Graham III, who had a history of domestic abuse, allegedly shot a nurse in the parking lot of Delta Medical Center. Using a carried-in revolver, Ramon Duckworth shot his hospitalized wife and then himself at Winter Haven Hospital in Florida. A similar situation earlier hit Hillcrest Hospital in Mayfield Heights, Ohio. In Jacksonville, Fla., Jesse Prindle wounded his son and killed his son’s mother before taking his own life in the parking garage of Baptist Medical Center following a custody dispute.

Earlier this year, a gunman who hospital workers described as “disturbed and disoriented” charged into the emergency room at Children’s Hospital Oakland in California. The gunman ran past a security officer, grabbed a female hospital worker and briefly held the gun on her before being subdued by police, according to a hospital spokeswoman. The disturbance began about 3:15 a.m., ending about eight minutes later. “Hospital security and our medical staff reacted calmly and tried to convince the man to drop the gun,” she said after the incident. Oakland police arrived within minutes to set up a perimeter, stationing officers with rifles around the hospital entrance.

Such situations are happening more routinely.

A couple of years ago, the American College of Emergency Physicians revised its guidelines asking hospitals to “provide a best-practices security system including adequate security personnel, physical barriers, surveillance equipment and other security components.”

In a rare move, federal OSHA recently cited Danbury (Conn.) Hospital for failing to provide adequate safeguards against workplace violence after an inspection which had been started through input from some hospital staff.