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Violence in hospitals is a serious occupational health and safety (OHS) issue affecting the physical and mental health of front line staff, as well as, the quality of patient care. In 2010, the province of Ontario (Canada) introduced legislation that directs hospitals to put into place violence prevention and management systems. Our study examined how five Ontario hospitals have developed and implemented their violence prevention programs.Semi structured interviews were conducted with eight key informants external to hospitals (legislators, union leaders, hospital associations), management and occupational health and safety specialists in hospitals (n=40), 21 focus groups (n=115) and interviews (n=6) with front line workers. Five hospitals participated in the study. Interview and focus group questions focused on the effect of the legislation on the development of violence prevention programs and how these were implemented across departments. Once data were collected, a code list was developed by the research team by reviewing the transcripts. Each transcript was coded by two researchers and then a thematic, inductive analysis was carried out. The constant comparative method was used to identify differences and similarities across hospitals and to understand factors that shape hospital policies and practices in the area of violence prevention and management.Our study findings suggest that while legislation sets parameters for the development of policies, serious violence-related events and the presence of a violence prevention ‘champion’ bolster long-term commitment to violence prevention in hospitals and the development of sustainable programs. We discuss four key components related to the prevention and management of violence in hospitals, namely; security systems, patient ‘flagging’, codes and alarms and incident reporting.Our findings detail how management commitment, workplace culture and broader structural factors can shape the implementation of hospital policies around violence prevention and reporting. Study recommendations focus on the long-term sustainability of violence prevention practices in the acute care sector and the implications this can have on worker health.