EXECUTIVE SUMMARY
Healthcare organizations are at risk of active shooters. Hospitals and other facilities should reduce the risk where possible and prepare response plans.
- Emergency departments are at increased risk.
- Video surveillance and other technology can help.
- Staff should be trained to protect themselves.
Active shooters can threaten people in virtually any place or situation, but healthcare facilities may be uniquely at risk because they are open to the public and frequently experience violence from patients and others.
Hospitals and other facilities should create an active shooter program that reduces the risk as much as possible and includes a response plan.
Hospitals have always been vulnerable during and after active shooter situations, regardless of where the incident occurs, because they are an essential element to the immediate response and recovery process during and after the event, says Lisa Terry, CHPA, CPP, vice president for vertical markets in healthcare with Allied Universal, a company based in Santa Ana, CA, that provides security systems to hospitals and health systems. She is the author of The Active Shooter Response Toolkit for Healthcare Workers.
“Because of the unique environment that is healthcare, hospitals are considered soft targets. We must acknowledge that there have been a few active assailant/shooter events occurring within a healthcare setting, and the risk certainly exists,” Terry explains. “Hospitals are open to serve the public 24 hours a day, and often encounter a crisis mentality within the population that they serve. It can be said that a hospital is a microcosm of a city.”
In healthcare, anyone can be the first to encounter an active shooter or hostile event situation, but staff in the ED are at heightened risk, Terry says. EDs often are overcrowded and must be accessible by anyone presenting with a medical emergency at all times, so they are considered a high-risk area.
“There is no single variable of predicting acts of violence,” Terry says. “However, one predictor of future behavior is past behavior. It is important to conduct a review after other incidents occur.”
Start with EOP
A good place to start in addressing the active shooter risk is with the organization’s emergency operations plan (EOP), Terry says. The International Association of Healthcare Security and Safety (IAHSS) Workplace Violence Prevention Bundle1 and the Active Shooter Hostile Event Response Guideline are excellent resources in establishing standards that address the role of hospitals and healthcare systems in preventing, mitigating, and responding to these events.
If not already in place, Terry says hospitals should develop a threat management program that includes a standing threat assessment team. A security vulnerability assessment should be conducted on a regular basis as well as when new risks are recognized.
Terry says risk managers should consider these proactive security solutions and capabilities:
- More access control;
- Physical design of identified higher-risk locations;
- Duress/panic alarms;
- Video surveillance;
- Emergency/mass notification systems for staff, patients, and visitors anywhere on or adjacent to the property;
- Weapons detections systems, such as security dogs and handlers;
- Ongoing training and exercises within the organization as well as within the surrounding community.
Save Yourself First
Healthcare professionals should be taught that in an active shooter situation, their priority is to ensure their own safety, Terry says. This is a particularly important message for physicians and nurses whose first instinct might be to protect their patients.
“Healthcare workers have a personal and ethical commitment to be survivors and protectors. It’s a unique environment where employees also make a commitment to assume responsibility for protecting the lives of others,” Terry says. “It is important to train healthcare staff to ‘Survive First. Protect When Possible.’”
Ongoing combined training and exercises with local first responders is an excellent training method and can help instill the idea clinicians must protect their own safety if they are going to be useful to their patients.
A common training for priorities in active shooter situations is “Run, Hide, Fight”:
- Run: Quickly identify the two nearest exits. If possible, run and help others escape.
- Hide: If you are trapped in an office, treatment room, or areas with doors, quickly secure the door. Lock it, barricade in any way, and turn off the lights. If in an open area or hallway, immediately move into a room and secure the door. Assist patients as much as possible, remembering your own safety first.
- Fight: As a last resort, fight for your life if confronted with an active shooter. This may include distracting, screaming, throwing objects, or using makeshift weapons to disarm the shooter. Once decision to fight is made, commit to this action completely.
Another common method of training is the 4 As, developed by the Center for Personal Protection and Safety (CPPS) to immediately assess and mitigate risks of violence.2 Terry offers this summary:
- Accept that something seems out of place. This may be noticing doors are propped open, or a family member appears angry and anxious.
- Assess next steps. Options might include closing doors, assisting a patient or family member, or calling for help.
- Act on your best judgment. Commit to your actions.
- Alert law enforcement or appropriate leaders if necessary. Allow the proper officials to further evaluate a potential threat before it escalates.
Active shooter scenarios should be included in any workplace violence prevention program, says Georgia Reiner, risk specialist for the Nurses Service Organization (NSO) in the Healthcare Division of Aon’s Affinity Insurance Services in Philadelphia.
“Employers should empower nurses to identify signs of potentially violent behavior and how to respond in an active shooter situation,” Reiner says. “Active shooting incidents are relatively rare but, unfortunately, have been increasing in recent years. Nurses need to be educated and trained so they can respond quickly and potentially save lives.”
Hospital leadership must commit to preparing employees for an active shooter situation. That starts with identifying potential vulnerabilities at the facility. A vulnerability assessment should include identifying both internal and external risks and eliminating those risks to the extent possible.
Administrators also should provide a written plan for responding to active shooters, which may include evacuation or sheltering in place, Reiner says. Drills can teach staff how to carry out the response and allow leadership to critique the plans.
“Employee training should address different response options, assigning responsibilities to specific individuals,” Reiner says. “The response plan also needs to include special considerations for areas like the emergency department, operating suites, infectious disease quarantines, and vulnerable areas like the NICU and ICU.”
Allocate Resources Carefully
Budget constraints can affect planning, says Rochelle R. Sweetman, JD, risk management consultant with Marsh McLennan Agency in Sioux Falls, SD.
“To the extent that hospitals can provide additional security, they often apply those resources in the emergency department because that is one of the areas with the highest risk,” Sweetman says. “That may include metal detectors and a high presence of hospital security. But that can be a very expensive process to get that level of security in place.”
Deciding where to spend limited resources for security can be difficult. If a hospital considers installing metal detectors, it is reasonable to ask how many full-time equivalents that money would cover for floor nurses who could de-escalate an upset patient or family member before a shooting occurs. The same reasoning might apply to hiring additional security officers.
“These cost-benefit decisions have always been difficult in healthcare, but it can be especially difficult now with labor shortages and supply chain issues,” Sweetman says. “When you add in the thought of an active shooter and the potential for stopping a tragedy, the decision can be even more challenging.”
Among Top Threats
Active shooters in parking areas, on perimeter grounds, and inside medical service buildings predominantly rank in the Top 10 Likely Threats with High Impact of Loss compiled by Force Protect Security Consultants in Panama City Beach, FL. Founder Frank Finley works with healthcare facilities to improve security.
The ranking is based on comparing 87 different threat scenarios that may occur in a healthcare setting, he says. The perpetrators tend to stem from angry patients, disgruntled employees, criminal action such as robbery, outside relations such as a domestic conflict, or in some cases, violent extremists.
“Based on our risk assessment results, emergency departments, outpatient mental health, and certain specialty care clinics are at highest risk of an active shooter,” Finley says. “The introduction of the weapon threat typically stems from a patient approaching their maximum pain threshold and thus lashing out, or revenge toward a provider perceived not to listen to the patient’s needs or provide the immediate pain relief and/or medication.”
In the federal sector, including the Department of Veterans Affairs, Finley says additional high-risk departments include the compensation and pension office, quality management, and the executive leadership team or director, Finley notes. These departments are likely to experience an active shooter due to denied service-disabled compensation ratings or perceived lack of timely service.
Other factors can increase the risk, Finley says. These include the location of the facility (urban vs. rural), local crime operational tempo, perceived poor customer service, long wait times, disgruntled workforce, no means of screening, exposed staff, and lack of behavior recognition training for staff. A lack of standard operating procedures and rehearsals for active shooter situations also can increase the risk of injuries and deaths.
Hospitals should conduct a site-specific risk assessment and allow the results to dictate the risk mitigation measures to implement, Finley says. He suggests these options:
- Lock down all perimeter gates and building doors;
- Direct public traffic through a minimal number of entrances;
- Implement passive full-time weapon screening vestibules;
- Install behavior analytic camera systems;
- Position facial analytic camera systems to detect those on the FBI wanted list, terror watch list, and an internal “banned from property” list, or “requires escort” list;
- Protect reception desks/nurse stations with ballistic enclosures;
- Secure all doors with access control leading from public space to private exam space;
- Implement panic duress means at each keyboard and person-worn pendants;
- Implement defend-in-place mechanisms on doors.
History of Workplace Violence
Healthcare has long been identified as a higher-risk industry with respect to workplace violence, notes Charles Randolph, executive director of strategic intelligence with Ontic, a protective intelligence software company in Austin, TX. The American National Standard on Workplace Violence Prevention and Intervention recognized healthcare as a workplace violence “high risk” industry.3
The COVID-19 pandemic and new restrictions on abortion access have put added stress on patients, their families, and medical practitioners, contributing to increases in threats and violence affecting healthcare practitioners and facilities.
“Although the risk is often seen as coming from volatile patients directed at nurses, technicians, and doctors, healthcare facilities also face threats from current and former employees, including medical practitioners, as well as domestic violence threats from external sources to employees,” Randolph says. “Hospitals that are affiliated with medical schools or research institutions may also face threats from students or applicants, as well as external threats to researchers conducting experiments in sensitive areas or using animals.”
Workplace violence can affect any department within a hospital or healthcare setting, but departments or offices that are known areas of stress or emotional conflict may draw more threats and violent incidents, Randolph says. In addition to the ED, risk can be higher in ICUs, maternity units, and departments such as patient accounts or even parking facilities.
“All departments within a hospital or healthcare facility can benefit from training on how to de-escalate conflict, such as a hostile interaction with a patient or family member,” Randolph says. “They should also be trained in how to report threats and other troubling behavior, and why it is important to do so.”
Employer Obligations
In January 2022, The Joint Commission (TJC) issued specific workplace violence prevention requirements for hospitals and healthcare facilities.4 Randolph says the best way for hospitals and healthcare facilities to prepare for and prevent workplace violence is to follow those requirements. These include creating a multidisciplinary workplace violence prevention team, training the team on threat assessment and workplace violence prevention, preparing all employees on identifying and reporting threats and other troubling behavior, and installing a database to track and manage cases and incidents.
OSHA also has issued Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers,5 notes Denise Merna Dadika, JD, an attorney with Epstein Becker Green in Newark, NJ.
Healthcare employers should review the OSHA and TJC resources when developing and reassessing workplace violence prevention programs, as well as any state requirements that may apply. Programs should include annual staff training on violence response protocols, including de-escalation techniques, response to alarm systems, use of safe rooms, escape plans, and the reporting physical or verbal violence toward healthcare workers.
“Healthcare employers have an obligation under the Occupational Safety and Health Act’s General Duty Clause to maintain a workplace ‘free from recognized hazards that are causing or likely to cause death or serious physical harm.’ OSHA frequently cites employers for failing to take steps to prevent workplace violence, citing the General Duty Clause,” Dadika says. “Preparing and adhering to a robust workplace violence prevention program will assist employers in discharging their obligation under the General Duty Clause.”
Employees who suffer workplace injuries may seek compensation for injuries and lost wages under the employer’s workers’ compensation coverage, which generally will be the exclusive remedy available to an employee, Dadika says. However, an employee may proceed with a civil action where he or she can demonstrate their injuries were caused by an intentional wrong on the employer’s part.
REFERENCES
- International Association of Healthcare Security and Safety. Workplace violence prevention bundle. 2022.
- Center for Personal Protection and Safety. Shots fired for healthcare. April 5, 2016.
- American National Standards Institute. ASIS International and SHRM release American National Standard on Workplace Violence Prevention and Intervention. Oct. 20, 2011.
- The Joint Commission. Workplace violence prevention resources. 2022.
- Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2016.
SOURCES
- Denise Merna Dadika, JD, Epstein Becker Green, Newark, NJ. Phone: (973) 639-8294. Email: [email protected].
- Frank Finley, Force Protect Security Consultants, Panama City Beach, FL. Phone: (502) 836-4232. Email: [email protected].
- Georgia Reiner, Risk Specialist, Nurses Service Organization, Healthcare Division, Aon’s Affinity Insurance Services, Philadelphia. Phone: (215) 293-1178. Email: [email protected].
- Rochelle R. Sweetman, JD, Risk Management Consultant, Marsh McLennan Agency, Sioux Falls, SD. Phone: (605) 339-3974. Email: [email protected].
- Lisa Terry, CHPA, CPP, Vice President, Vertical Markets – Healthcare, Allied Universal, Santa Ana, CA. Phone: (919)796-8821. Email: [email protected].
- Charles Randolph, Executive Director, Strategic Intelligence, Ontic, Austin, TX. Phone: (512) 572-7400.
Active shooters can threaten people in virtually any place or situation, but healthcare facilities may be uniquely at risk because they are open to the public and frequently experience violence from patients and others. Hospitals and other facilities should create an active shooter program that reduces the risk as much as possible and includes a response plan.
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