Violence in Healthcare: Code White and Staff Safety

Why is violence in healthcare a separate topic?

Violence in healthcare has the same roots as violence in other jobs involving face-to-face work with customers, but differs in several respects. Patients and their relatives are often in fear, pain and uncertainty; waits are long, and the matter being decided is the health of a loved one. The emergency department is open day and night and its door is open to everyone. The worker, meanwhile, cannot refuse the service and walk away; they must care for the emergency patient.

For this reason, violence in healthcare facilities is dealt with through special Ministry of Health rules alongside general OHS rules. We covered customer assaults in workplaces such as shops, banks and call centres in our article on violence against workers; this article focuses on hospitals, medical centres, outpatient clinics and oral and dental health facilities.

Two sets of rules are applied together:

OHS legislation: Art. 4 of Law No. 6331 on Occupational Health and Safety obliges the employer to take all kinds of measures; Art. 8/3 of the Regulation on Risk Assessment requires psychosocial hazards to be recorded as well.
Health legislation: Art. 7 of the Regulation on Ensuring Patient and Staff Safety requires arrangements to prevent physical assaults on staff in healthcare institutions. The Ministry of Health’s Staff Safety Circular sets out the Code White procedure, reporting channels and internal measures in detail.

What is Code White and how does it work?

Code White is the internal emergency code announced in a healthcare facility when a violent incident against a member of staff occurs. When the code is called, security staff and the response team designated by the facility come to the scene; the incident is recorded and reported to the Ministry. The Ministry of Health has set up the 113 Code White line and a Code White website for these reports (Ministry announcement).

Under the Staff Safety Circular, the process works as follows:

Internal response: Code White is announced and the response team reaches the scene as quickly as possible. The procedure is monitored by a manager in the facility’s management.
Reporting to 113: Violent incidents occurring in all public and private healthcare institutions and facilities are reported immediately by the facility manager to the Ministry’s Code White Unit via the 113 line. The staff member subjected to violence may also call 113 directly.
Reporting form: The manager completes the Code White reporting form.
Judicial authorities: The incident is passed to the facility’s legal unit and the judicial authorities. The Circular stresses that the prosecution of violent incidents against public servants does not depend on a complaint; the manager refers the incident to the judicial authorities regardless of whether the staff member has filed a complaint.
Withdrawing from care: The staff member subjected to violence may request to withdraw from providing care to that patient, except for services that must be provided urgently; if the request is accepted, another staff member or facility is designated for the patient’s treatment.

Reporting violence against health workers: which channel, and when?

A violent incident can give rise to several independent reporting obligations. None of them replaces the others:

Channel	Who reports?	When?	Which incidents?
Internal Code White	The staff member experiencing or witnessing the incident	At the time of the incident	Violent incidents defined in the facility’s procedure
113 Code White Unit	The facility manager; staff may also call directly	Immediately	Violent incidents
Legal unit and judicial authorities	The facility manager	Immediately	Violent incidents
SGK occupational accident notification	Employer	Within 3 working days of the accident	Incidents in which a staff member is injured
OHS incident record	The workplace health and safety unit or OSGB	After the incident	All incidents, including near misses

The situation of a staff member assaulted and injured while working is an occupational accident: Law No. 6331 defines an occupational accident as an event occurring at the workplace or because of the conduct of work that impairs physical or mental integrity. For the notification steps, see our article on SGK occupational accident e-notification.

Violence in the emergency department: layout and organisation

The emergency department is the unit where violence in healthcare is most common. The Circular requires sufficient security staff in emergency department, intensive care and operating theatre waiting areas, security cameras able to monitor all areas of the facility while respecting patient privacy, adequate lighting of spaces and alternative exit routes for staff. On site you can apply these principles as follows:

Waiting area: Waiting times and order of priority are announced clearly. Under the Circular’s “problem solver” practice, people trained in communication and conflict management are assigned to waiting areas.
Triage and registration desk: The desk is deep enough that no one can reach across to the staff member; behind the staff member there is an exit to a staff-only area.
Examination room: No patient or relative should get between the staff member and the door; the desk and couch are positioned accordingly. Heavy or sharp objects that could be thrown are not left out in the room.
Access control: The number of relatives entering the treatment area is limited and entry is controlled.
Alarm: Examination rooms and desks have a way of silently triggering Code White (an internal phone code, an alarm button), and every shift knows it.
Training: The Circular provides for communication and anger management training for security staff and emergency staff, and training on measures against violence for all health workers.

In the emergency department, the night shift is often when the most intense tension occurs with the fewest staff. Plan the number of security staff and the Code White team according to night and weekend duty, not the daytime establishment.

Measures against violence in healthcare: outpatient clinics and small facilities

A small outpatient clinic, medical centre or dental clinic may not have a separate security unit; the risk is still there. Practical measures against violence in healthcare:

Appointment and waiting management: Delays are communicated to patients early; long waits are a frequent starting point for violent incidents.
Fee and billing discussions: Payment disputes are handled at a separate point, not in the examination room, and with an authorised person.
Reducing lone working: It is planned that the physician or nurse is not left alone in the building in the evening.
Desk layout: The staff member’s access to the door is kept clear.
External support: In a facility without security staff, the emergency plan states who will call 112 and where staff will withdraw to during an incident.

For risks specific to dental clinics, see our article on OHS in dental clinics.

Post-incident support and recording

When the incident is over, the staff member’s needs begin. If there is an injury, a medical assessment is carried out; even if there is no visible injury, the staff member meets the workplace physician. The staff member is not sent back to a high-tension area on that shift and, if they wish, their place of duty or shift is temporarily changed. The manager’s conversation is aimed at understanding the incident, not assigning blame; the staff member is given guidance in the legal process.

Repeated violence and tension are an important source of burnout in health workers; for symptoms and measures, see our article on burnout syndrome. Occupational accidents and near misses require the risk assessment to be renewed regardless of its validity period; after each incident, the layout, staffing plan and training are reviewed.

Bursa Sistemer enters the risk of violence in private healthcare facilities in Bursa and neighbouring provinces into the risk assessment work, and the Code White flow and staff withdrawal routes into the emergency plan. For the sector’s other risks, see our healthcare facilities page, and to see the minimum specialist and physician time for your facility, the OHS obligations calculator tool.

Frequently Asked Questions

What is Code White?

It is the internal emergency code announced in a healthcare facility when a violent incident against a staff member occurs. It calls security and the response team to the scene; the incident is also reported to the Ministry of Health Code White Unit via the 113 line.

Must private clinics also report to 113?

Yes. The Staff Safety Circular lays down the reporting provision for all public and private healthcare institutions and facilities. The facility manager makes the report; the staff member subjected to violence may also call 113 directly.

Should verbal violence also be recorded?

Yes. Verbal violence is often the first stage of a physical assault and should be included in the risk assessment as a psychosocial risk. Internal records show in which unit measures should be concentrated.

Is an occupational accident notification needed for an assaulted health worker?

The situation of a staff member assaulted and injured while working is an occupational accident and is notified to SGK within 3 working days of the accident. This notification does not replace the reports made to 113 and to the judicial authorities.