From Coverys Risk Management

From schools to shopping malls, it seems that no public place is safe from the threat of violence, particularly in the form of an active shooter. If your healthcare facility faced such a threat, would you be prepared?

What Is an Active Shooter?

Homeland Security defines an active shooter as “an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearm(s) and there is no pattern or method to their selection of victims.” Active shooting events are unpredictable, evolve quickly, and require law enforcement intervention.

In an FBI report regarding a total of 160 active shooter incidents between 2000 and 2013, the statistics show that such incidents have increased in frequency. The first seven years of the review period reflect an average of 6.4 incidents annually, while the latter seven years show 16.4 incidents annually, with more than 1,000 casualties (486 killed, 557 wounded — excluding the shooters). More than half of the incidents ended on the shooter’s initiative (e.g., committed suicide, stopped shooting, fled the scene), while 13% of all incidents ended after unarmed citizens successfully restrained the shooter.

While healthcare facilities experienced only a small portion of the active shooter events studied in the FBI report — 154 hospital-related shootings between 2000 and 2012 — it is still vitally important for healthcare facilities to prepare for the possibility of an active shooter situation. It’s also important that you consider the unique challenges associated with active shooter incidents at healthcare facilities. Your staff may feel conflicted about leaving patients, and evacuations may be limited due to medical procedures in progress, as well as the age, illness, or injury of patients. Having an established plan for responding to an active shooter can make a significant impact not only on the outcome of the situation but also on your staff members’ ability to respond quickly and appropriately.
To be optimally prepared for an active shooter incident, consider the following recommendations to help your facility prevent, reduce, or limit the shooter’s access to potential victims and reduce or prevent casualties.

Recommendation #1: Develop an Active Shooter Response Plan

Planning is essential to minimize the potential for an active shooter event and maximize the response. For the most comprehensive approach, you should consult with facility stakeholders, local law enforcement, and legal counsel. Also, your active shooter plan can be incorporated as part of your broader hazard response plan.

A well-crafted active shooter response plan should first address how the plan will be activated. Overhead paging may not be the most appropriate approach. Successful alternatives to paging include blast emails and texts and autodialing systems with recorded messages that simultaneously call designated telephones (similar to Reverse 911). Remember that people with limited English proficiency or sensory disabilities needs to be informed, so your plan also needs to address how to notify such individuals.
Another key component of your plan is having defined evacuation routes for each department and area of the facility. To successfully use these evacuation routes:
  • Mark the evacuation routes on floor plans and include copies in Incident Command boxes.
  • Provide law enforcement with current copies of all floor plans; include the designated escape routes.
  • Be sure to include directions for alternative escape routes that can be used if the designated route is not safe.
Because it’s not always possible for all individuals in your healthcare facility to evacuate during an emergency, it’s vital that you have one or more defined shelter-in-place option(s) for each department. The most effective shelter-in-place locations “have thick walls, solid doors with locks, minimal interior windows, first-aid emergency kits, communication devices, and telephones or duress alarms." Your plan should also provide additional directions in case the primary shelter-in-place location is not accessible.
Your plan should outline how to lock down the facility as quickly as possible to keep people away from the building(s) and the shooter. Optimal lockdown may include locking doors internally, as well as perimeter doors. In addition to preventing more people from entering the facility and becoming victims, your plan should have provisions for how to implement traffic control; aside from law enforcement and emergency vehicles, all movement — of vehicles and pedestrians — should be away from the building.
Finally, and very importantly, your plan should clearly outline how to account for staff members, patients, and visitors during and after the event. Healthcare facilities where employees use ID badges often have practices and technologies to assist with this challenge.

Recommendation #2: Train Staff Members for Active-Shooter Incidents

A well-developed plan is only truly useful if staff are trained to implement the plan in an emergency. As such, it’s essential that you develop and conduct training on a regular basis. The Joint Commission recommends addressing the following during employee training and drilling:
  • How to respond to active-shooter events: each employee should understand their unique responsibilities
  • What to expect from law enforcement: employees must understand that law enforcement’s primary goal is to contain the shooter
  • How to evacuate patients
  • How to shelter in place and protect patients who cannot be moved
  • Risk strategies for high-risk security sensitive areas (e.g., emergency department, operating rooms, and pharmacy)
  • Incident Command support training for security personnel and other employees
  • Conducting periodic drills and debriefing staff members after each drill to identify opportunities for improvement.
Recommendation #3: Develop a Process to Identify High-Risk Situations

Develop a process to flag the records of patients with a known history of violence. Contingency plans should be in place for these patients, such as adding additional staffing, reducing wait times, and supervising their movement through the facility. Consider the following guidelines for mitigating the risks associated with high-risk situations:
  • Encourage staff members to report concerns related to domestic violence or active threats of violence. Some healthcare facility-related shootings have been related to domestic disputes.
  • Encourage staff members to report visitors and family members who are exhibiting unusual behavior or making violent or aggressive comments.
  • Develop a strategy for dealing with weapons brought into the facility:
    • Determine which staff members are responsible for requesting that a weapon be surrendered.
    • Establish a process to turn over surrendered weapons to law enforcement.
    • Provide the patient with a claim ticket to claim their weapon with law enforcement after being discharged from the facility.
While active shooters may be patients or random individuals, it’s also important to acknowledge the possibility that an employee (current or former) could become an active shooter. Be vigilant about employees who exhibit potentially violent behavior. Indicators of such behavior include:
  • Increased use of alcohol and/or illegal drugs
  • Unexplained absences from work and/or vague physical complaints
  • Depression or withdrawal
  • Increased or more severe mood swings and/or noticeably unstable, emotional responses
  • Increased mention of problems at home
  • Increased unsolicited comments about violence, firearms or other dangerous weapons, and violent crimes.
While there is no way to absolutely predict or prevent an active-shooter situation, your facility can reduce risks by developing an active shooter response plan and working with local law enforcement.

Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.