Ma Zhen-Sheng et al: How can violence against doctors in China be prevented?

mazhenshengOn 10 January 2014, a four year old female was hospitalized with fever in the department of pediatrics of Xi’an Central Hospital in Xi’an City, Shaanxi Province, and was discharged after six days of treatment. She was readmitted to the hospital with pneumonia two days following discharge, and was subsequently transferred to Xi’an Pediatric Hospital in a critical condition. Despite 30 hours of intensive care treatment in the Xi’an Pediatric Hospital, she succumbed to the infection. The following day more than 20 of the child’s family members attacked the department of pediatrics in Xi’an Central Hospital, injuring four doctors and nurses and two policemen [1].

In 2005, the Chinese Hospital Association organized a survey demonstrating an increase in violent and destructive behavior towards hospitals and their medical staff, where more than 10 000 doctors had been attacked and injured each year. In 2010, there were 17 243 cases of violent attacks against healthcare workers. Over 30 doctors and nurses have been killed by patients, and two doctors committed suicide because of medical disputes with patients from 2001 to 2013. Some of the hospital attacks are repetitive and group events.

With the rise in violence against healthcare professionals, more hospitals have hired security guards and set up a police room in cooperation with the local public security bureau. Some hospitals have even invited policemen to serve as the vice president of the hospitals [3]. On 4 May 2012, the Ministry of Public Security and the Ministry of Health (now the National Health and Family Planning Commission) jointly issued a public notice demanding that all hospitals above Level 2 have a police station and a policeperson on duty at all times to reduce crimes against healthcare providers. Despite this legislation, in 2012 there were 11 episodes of severe violence against healthcare professionals which resulted in seven deaths and 28 injuries [2].

In 2007 and 2013, I organized two surveys on safety and security guards for orthopaedic surgeons, and a total of 790 surgeons participated in these surveys. These have been submitted for publication, but are not yet published. Nearly 80% of participants have been attacked and injured physiologically and/or psychologically, and nearly 88% of participants said there would be no compensation after being attacked and/or injured at work. The percentage of surgeons who worked in hospitals in which security guards or protective services were present increased from only 25% (2007) to 94% in 2013. The security guards are generally responsible for fire prevention, transportation monitoring, keeping orders, and patrolling the inpatient and outpatient departments of the hospital. However, while 81% reported that the security guards patrol on schedule in hospital, only 63% reported that the security guards can provide timely protection when attacks happen. While 72% reported there is a police room in their hospital, only 45% reported that there is policeperson on-duty.

The National Health and Family Planning Commission issued a guideline on “Strengthening the Establishment Hospital Security and Safety Guarding System” in October 2013. Hospitals above Level 2 should have security guards for every 20 beds, or over 3 per 1000 of daily outpatients. The hospitals should establish four safety systems, including an invading warning system, closed-circuit television (CCTV) system, an entrance and exit control system, and an electronic patrol system [2, 5]. How did the National Health and Family Planning Commission get the standard ratio of one security guard for 20 beds? Was it calculated based on a scientific research on hospital safety?

Based on the new guideline, one security guard is required for 20 beds, yet each guard only works eight hours based on Chinese labour law. Thus three guards are required to protect 20 beds for 24 hours. While a small ward has 40 beds, more commonly wards have about 100 beds, which would require five security guards around the clock. The costs to the hospital may outweigh the benefits.

While the attackers prepare well for what they want to do, it seems that the hospitals are not prepared to intervene in a timely manner to protect health workers. For example, just after the guidelines were issued, three doctors were stabbed in the First People’s Hospital, Wenling City, Zhejiang Province, and one doctor was killed. The killer had been hospitalized for deviation of the nasal septum, chronic rhinitis, left maxillary sinusitis, and ethmoidal sinusitis, and was treated by bilateral submucosal partial resection of the inferior turbinate. The surgery was successful, as confirmed by follow-up CT scans and discussions among doctors of the department of ENT from different hospitals. The killer thought the surgery was a failure and issued a death threat to the doctor, yet no protection was provided. He then stabbed three doctors, one of whom died. The security guards and policemen did not respond in time to the event [4]. Threats from patients and/or family members are often addressed with a verbal warning from security staff, which is insufficient, and the attacks and killing continue in hospitals in China.

1. Over 20 patient family members smashed Xi’an Central Hospital and injured doctors. Data posted on January 22, 2014, last accessed on February 12, 2014

2. National Health and Family Planning Commission and the Ministry of Public Security of China cooperatively issued a Guideline on Strengthening the Establishment Hospital Security and Safety Guarding System. Data posted on October 22, 2013, last accessed on February 12, 2014

3. Policemen were invited to be vice president in 27 hospitals in Shenyang City, Liaoning Province for preventing violence against hospitals. Data posted on July 5, 2010, last accessed on February 12, 2014

4. The killing-doctor suspect in Wenling City wrote death List on the wall of his bedroom. Data posted on November 1, 2013, last accessed on February 12, 2014

5. The National Health and Family Planning Commission. One safety guard for 20 beds in hospital above level 2 for preventing violence against healthcare system. Data posted on October 10, 2013, last accessed on May 6, 2014

Acknowledgement: Thank you to David A. Speigel from the Department of Orthopedic Surgery, Perelman School of Medicine at the University of Pennsylvania for his kindness and help in revision of the manuscript.

Ma Zhen-Sheng, Lin Wang, and Sang Hong-Xiong, department of orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi’an, China.