How Should Hospitals Prepare for Active Shooter Threats?

By Mike Cummings, CPP

Hospitals and other healthcare facilities are in a unique position relative to active shooter threats and other types of workplace violence.

As opposed to other types of critical infrastructure such as banks and factories that are tightly locked down under multiple layers of security, hospitals are generally open and accessible to nearly all members of the public—such as emergency departments (ED) that operate 24 hours per day, seven days per week, and 365 days per year.

“Unlike other businesses, the major problem with active shooter incidents in a healthcare facility is that unique challenges are posed in planning and response,” according to the book Active Shooter Response available through the National Library of Medicine.

Since 2000, there have been 154 documented hospital-related shootings involving 148 hospitals. These shootings resulted in 235 injuries, and in some cases, death. Over the last two decades, hospital-related shootings appear to be growing in frequency and have been known to happen in hospitals of all sizes, with at least 51% of shootings occurring in hospitals with less than 40 beds, according to the book.

Interestingly, as the number of hospital beds in a hospital increases, the number of shootings drops, which may indicate that small hospitals are easier to maneuver and have less stringent security than their larger counterparts. About 60% of shootings have occurred inside the hospital, and 40% outside. The most common hospital locations for shootings include EDs, inpatient clinics, and parking lots.

Foundational elements of an active shooter program

Establishing an effective active shooter prevention and response program begins with recognizing that it should not exist in isolation. Rather, it must be a component of a broader workplace violence prevention strategy. By integrating existing policies and infrastructures—such as training systems, command centers, and communication protocols—healthcare organizations can ensure consistency, efficiency, and interoperability in emergency scenarios. The benefits of establishing consistent staff response to multiple emergency situations can be especially helpful in simplifying training efforts to ensure that all staff are prepared to respond quickly and correctly.

General considerations when building an active shooter program include the size, scope, and complexity of the healthcare facility. For example, a large, urban hospital with dedicated security staff will have vastly different capabilities than a small, rural clinic with minimal overnight staffing. Planners must assess the unique risks of their facilities through thorough site assessments and gap analyses, which help identify vulnerabilities and set priorities for action.

Creating a robust plan also requires assembling a multidisciplinary team. This team should include representatives from senior leadership, security, human resources, legal, risk management, clinical and nursing leadership, internal and external communications, switchboard operations, and training departments.

These stakeholders bring diverse perspectives and operational expertise that help shape an all-encompassing response plan, from real-time threat detection to post-incident debriefs and revisions. Furthermore, coordinating with external emergency responders and law enforcement during the planning phase ensures a clear understanding of available resources and mutual expectations in an emergency.

Education and training are paramount

One of the most critical pillars of an active shooter program is education and training. All staff, not just security or clinical personnel, need both general and role-specific instruction. This includes understanding emergency procedures, knowing how to use emergency communication systems, and being competent in response strategies such as the FBI’s “Run, Hide, Fight” principles.

Training must be ongoing and documented, with added frequency for roles with higher responsibilities or turnover. Importantly, training should not be a mere checkbox exercise; it must ensure that staff can demonstrate proficiency in crisis protocols, such as knowing how to physically lock down a unit or use emergency call buttons.

Wearable smart badges that feature emergency call buttons can be particularly effective in enabling rapid response to active shooters. By allowing staff members to immediately summon security with the touch of a button, these devices provide reassurance to staff, reduce incident response times, and foster a safer workplace environment. Today’s state-of-the-art smart badges leverage RTLS technology to send the badge wearer’s real-time location when an alert is sounded, which can power a more rapid and accurate response from security. The best staff safety solutions also include full outdoor coverage. With this advancement, hospitals can now provide comprehensive staff protection beyond the indoors and throughout their campuses—including parking lots, garages, drop-off zones, and walking paths.

Response protocols should clearly establish the criteria and steps for activating an emergency response. This includes identifying a single intake point, often the switchboard, for internal and external communications. Hospitals should also have pre-established command centers, lockdown procedures, and systems for disarming utilities when necessary. Specific attention must be given to patient safety, recognizing that many patients cannot evacuate independently. Nurses and caregivers often remain with patients during crises, so protecting these areas with secure doors and rapid lockdown capabilities is vital.

Drills play a key role in preparedness, but caution is required. Unlike fire or weather drills, active shooter simulations should never be conducted as “real” scenarios due to the risks of confusion and potential violence, particularly in states where off-duty personnel or visitors may be armed. Instead, hospitals should use clearly marked drills, held at varied times and shifts, with observers documenting performance and identifying areas for improvement. These drills help ensure that policies are not only in place but effective in real-world conditions.

Communication during an active shooter event must be immediate, accurate, and universal. Many hospitals have moved away from using color codes—like “Code Silver” for active shooter—in favor of plain language announcements such as “Active shooter in the ED,” to avoid confusion and ensure that everyone, including patients and visitors, understands the nature of the threat.

Communication plans should also include coordination with first responders, media management, and protocols for family notification and reunification. Given the chaos that follows such events, having a system to efficiently communicate with staff and the public is essential to maintaining order and safety.

Protection from a growing threat

Hospitals face unique challenges in preparing for active shooter threats due to their open, accessible nature and the presence of vulnerable patients. A successful prevention and response program must be built on existing workplace violence structures and tailored to the facility’s specific needs and risks.

By forming a multidisciplinary planning team, prioritizing education and competency-based training, developing clear response protocols, conducting realistic and safe drills, and ensuring robust communication systems, healthcare facilities can significantly enhance their preparedness and ability to protect staff, patients, and visitors in the face of this growing threat.

Mike Cummings is a Board-Certified Protection Professional (CPP) with over four decades of experience in safety management, threat mitigation, and operational strategy. As Chief Security Adviser at Kontakt.io, he spearheads initiatives that empower healthcare facilities with cutting-edge IoT solutions to improve patient safety, staff efficiency, and real-time visibility.