“Acknowledging the flags”: A quality improvement project on violence flags in the Emergency Department

Background: Violence flags are communication tools placed on patient’s charts to alert healthcare workers about potential risks of violence, particularity in high-risk exposure settings such as emergency departments. Although intended to mitigate workplace violence, these flags were found to be associated with inequity in care and patient stigmatization when inappropriately implemented or poorly documented. Objective: This project aimed to explore existing violence flag practices and implement an educational intervention to review current practices, highlight the benefits and risk of violence flags and reinforce standardized policy directives to promote equitable care and reduce harm. Methods: This quality improvement project was conducted at The Ottawa Hospital (TOH) using a multimethod approach from December 2025 to February 2026. Phase one consisted of a cross-sectional retrospective analysis of pre-audits featuring documented violent flags initiated within the last year up to 5 years. Phase two used a quasi-experimental paired sample study designed to measure the impact of a 15-minute educational intervention on violence flags delivered to 40 emergency nurses (RNs and RPNs). Participants completed pre- and post-intervention questionnaires assessing knowledge of TOH’s institutional policy on violence flags, level of agreement with literature-informed statements on flags using a 7-point Likert scale and provided feedback on the education. Results: Analysis of the pre-audit data on violence flags at TOH (n = 33) showed that workplace violence were mostly related to physical violence from patients, accounting for 70% of cases. While pre-audits captured high flag accuracy in flag documentation after initiation (100%) and flag correspondence (82%), documentation of trigger identification and strategy descriptions were low (15% and 12%) with no recorded use of the standardized smart phrase “.violentfyi” revealing gaps in comprehensive documentation as outlined in the policy. Following the educational intervention, participants demonstrated a significant knowledge improvement on violence flags with mean correct scores increasing from 59% pre-intervention to 82% post-intervention (95% CI: 1.76–2.78, p < 0.001). Additionally, 80% of position statements showed significant shifts in perception including increased awareness of equity concerns related to violence flags (p < 0.001 to p = 0.03), reduced agreement with flag permanency (p = 0.03) and greater confidence in flag application (p < 0.001). Implications and lessons learned: A brief educational intervention supported by pre-audit data on violence flag practices was found to effectively improve emergency nurses’ knowledge and awareness on flag utilization and documentation, promoting equity-focused flag practices. These findings support the integration of targeted education on violence flags into routine training to enhance professional competency, foster best practices promoting equitable care and reinforce workplace safety. Further evaluation of this intervention is warranted to determine its long-term sustainability and impact on documentation practices, patient outcomes and workplace safety through post-intervention audits.