Protecting your Patients: Violence and Active Shooters

John Palmer

Healthcare facilities are increasingly becoming the target of violent acts. Many healthcare experts suggest that healthcare facilities should take a close look at their violence prevention plans, practice response plans with employees, and take extra precautions to shore up their facility’s physical environment to make sure staff are as safe as they can be. 

“We are in an environment where underlying violence is considered acceptable,” says David Callaway, MD, FACEP, director of operational and disaster medicine at Carolinas Medical Center in Charlotte, North Carolina. “We are expected not only to survive, but to turn right around, respond, and treat casualties.”  

OSHA and The Joint Commission, as well as CMS, are taking workplace violence very seriously. In 2016, an update was issued to its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, known to many in the healthcare safety field as OSHA Rule 3148. A response to a higher incidence of active shooters and other violent events in healthcare facilities, OSHA published the update to help facilities improve their preparations for violent incidents. In addition, The Joint Commission has issued directives to start looking at the ways that hospitals mitigate potential violence in surveys. 

General violence prevention 

Know who your patients are, and talk to your coworkers.  

People who commit violent acts against healthcare facilities are usually well-known to the people who work there. Offenders may be furious at a doctor for being unable to save the life of a loved one, angry at a large bill they are having trouble paying, or upset at their estranged spouse who works at the facility. Just one of these kinds of events happened on January 20, 2015 when Stephen Pasceri, 55, of Millbury, Massachusetts, walked into the Carl J. and Ruth Shapiro Cardiovascular Center at Brigham and Women’s Hospital in Boston, and asked to speak with Dr. Michael J. Davidson, who had treated his mother. When the two stepped into an exam room to speak, colleagues reported hearing loud voices and then two shots fired as Pasceri shot and killed Davidson and then himself. 

The shooting spurred Brigham and Women’s Hospital, as well as other Boston hospitals, to conduct their own security assessments and increase drills. 

Whatever the case, it’s a good idea to know who is coming into your facility and communicate with them. If a patient or family member is known for having anger issues or makes threats against your employees, this is something that should be communicated and well documented on a list. Front desk personnel and security officers should know who they are dealing with, and in extreme cases, the police should be notified. Consider banning that person from your facility, but remember that decision may also make the person angry. 

Put people in the waiting room.  

A leading cause of violence in healthcare settings is anxiety caused by long waits in the waiting room. One of the best ways to mitigate this is to reassure those waiting to be seen by the doctor that they are important, safe, and will be seen soon. Doing something to calm nerves could be the one move that keeps an anxious person from becoming violent in your emergency room. 

Recognize the warning signs.  

There are days that will be busier than others, and on those days staff may not have the opportunity to check on the people in the waiting room. Those are also the days when patients will be the most anxious. On such days, too, you will be more likely to miss some of the most common warning signs that signal imminent violence. 

Experts on healthcare safety say nonverbal body language known as “behaviors of concern” can precede actual violence, and if caught early, de-escalation tactics can be used to intervene and keep the situation from becoming violent. 

Be on alert for the telltale signs of stress and anxiety, including raised voices or fast talking, clenched fists and teeth, glaring eyes, and fixed or darting stares. These behaviors of concern work on a sliding scale and can usually be defused with simple tactics such as calming talk, offering a glass of water, or allowing the person to sit in a quieter area to relax. 

Put up your own signs.  

You are the environment that you promote, and letting people in your hospital know that violence will not be tolerated is a deterrent in itself. Many facilities have taken a “zero-tolerance” approach to violence and will let those inside their walls know about it. Let patients and visitors know they are being watched, and that any violent or aggressive acts will be taken seriously and reported to the police.  

Don’t let workers be alone.  

Whenever possible, employees should be encouraged to work or walk with a buddy when in the parking lots or other scarcely populated parts of your facility. A show of numbers can be a deterrent for violence. It gives them a backup (and someone who can summon help if needed); a buddy also ensures there is a witness nearby to help document any violence or strange happenings that may be unfolding. A buddy also can do what law enforcement officers do at traffic stops—while one person is focusing on the task at hand (such as filling a syringe), the other can be watching the patient to ensure he or she is not about to attack or become violent. 

Your facility 

Install locks and barriers.  

This sounds like a no-brainer, but many nurse stations and intake areas are still very vulnerable because they do not have the proper locks installed. Exterior doors should latch when closed, and interior doors leading to the patient care areas—as well as rear doors in the back of the facility—should always lock when closed behind someone. Install glass or plastic partitions (bulletproof is best) that enclose front-desk personnel and protect them from violent individuals. Lastly, instruct your personnel to make sure they always keep exterior doors shut; this is a major problem during warmer weather when the temptation is there to open some back doors and let the fresh air in. 

Beware of tailgaters.  

Are you sure that doctor is supposed to be in your hospital? Make sure you double-check. Brigham and Women’s had a breach in September 2015 when it was discovered that a “fake doc” had for several days roamed the halls of the hospital unchallenged, dressed in scrubs, asking questions at a lecture, attending patient rounds, and observing operation—even helping transport a patient to the recovery unit, according to a report in the Boston Globe. 

Cheryl Wang, 42, a former surgical resident who had been dismissed from a program in Mount Sinai St. Luke’s Hospital in New York City and had been reported to New York’s state disciplinary board, somehow blended in with the circulating mass of medical personnel, slipping into restricted areas and suggesting she had connections to an attending doctor. 

At some point, physicians caught on and Wang was escorted off the property. Meanwhile, hospital officials posted her photograph near operating rooms and alerted other hospitals in Boston. The next day, she showed up for rounds in a conference room at Massachusetts General Hospital and was told to leave. Astonishingly, when she left, she was followed by Brigham officials to Children’s Hospital Boston, where she tried to do the same thing—she was intercepted and turned away, the Globe reported. 

Wang took advantage of this busy environment, hedging her bets that she wouldn’t be noticed as an outsider among the many other doctors, nurses, and residents at the hospital every day. It’s called “tailgating,” a problem that security experts have warned against for years. In this practice, hospital staff hold ID badges against the electronic card reader to gain access to surgery suites, and then groups of people hold the door for one another, not questioning that someone dressed in the same medical garb might not belong there. 

Secure furniture.  

Many waiting areas and patient rooms have lightweight furniture, lamps, tables, and other items that could be wielded as weapons. It’s a good idea to go through your waiting room and somehow tie or clamp down furniture (inexpensive clamps can be bought at a hardware store); alternatively, you can buy weighted furniture that is much harder to lift and does not contain glass or other potentially sharp edges. 

Establish safe rooms.  

In the event that violence does break out, there should be a designated room that staff and that patients can go to escape, especially smaller facilities where there isn’t a lot of room. Staff should be trained to run, look for a room they can barricade themselves and their patients in, and lock the door to keep violent individuals out. Also, designate an area outside the facility where employees can meet up if necessary.  

Check your phone lines.  

If you don’t have working phones, you have other issues to deal with. But it’s probably a good idea to double-check that your emergency contact number list is up to date and that your communication plans are in good working order. If a violent incident occurred up front, who would the front desk nurse call for help? Is there an alarm or code that would sound to let everyone in the office know of the situation? Your staff may know to call 911, but would they know what to say? Perhaps now is a good time to write a list of emergency numbers and maybe even a short script callers will follow when calling for help. It’s also a good time to rehearse your emergency plan or invest in walkie-talkies so your staff can communicate with each other. Also, many police and fire departments will be happy to send representatives to your facility and talk security. It helps them, too—they become familiar with your place in case they ever have to respond. This is all part of the emergency preparations that The Joint Commission, CMS, and other accreditation agencies require, and you should be drilling them on a regular basis. 

Staff training 

Teach them to relax.  

During a chaotic situation, things are going to get stressful. In most cases, the coolest heads will prevail, and if there’s a gun or weapon involved, the person who is able to keep calm and defuse a situation could save lives. Many healthcare security experts agree that violence stems from anxiety and fear, and they recommend de-escalation tactics that focus on calm talking and nonverbal language—these can give the message that you sympathize with the person. Learning these tactics can help defuse a situation and give you the upper hand, and the person may even wind up surrendering his or her weapon, helping to stop a major incident. Call your local police department or consult one of the many sources on the web to find a program that works for you. 

Fight as a last resort.  

Many hospital facilities have turned to government agencies such as the FBI and the Department of Homeland Security to teach participants to run, hide, and fight during a violent incident. But in a healthcare setting, that sort of training won’t work, since most physicians and nurses would not leave their patient’s side during a shooting. 

Callaway says Carolinas Medical Center has begun using a different system (Avoid, Deny, Defend, and Treat) as an alternative response plan during a shooting incident. Here’s a breakdown of how it works: 

>Avoid. Hospital staff need to develop habits that will help raise situational awareness and let them avoid a shooter situation in the first place. They should know their location’s access points and take the time to engage them (e.g., by making sure doors are locked). They also need to engage people. What is the look in visitors’ eyes? Are their hands in their pockets? Are they hiding something? Will they give a handshake if one is offered? By engaging people, you may be able to avoid an active shooter incident from occurring. 

>Deny. This is the “hide” part of the system. Almost half of active shooter incidents end within five minutes, and victims are usually chosen at random. Staff members need to be trained to quickly recognize when an incident is about to get violent; they should find a safe room they can quietly hide in with patients and barricade with things such as beds, chairs, or other objects. 

>Defend. Only as a last resort should a staff member in a healthcare setting fight back, and even then it’s a personal decision that should be made deliberately. Staff should always understand that it is never a job requirement to put their life in jeopardy. If an employee does choose to fight back, such as in a face-to-face confrontation with a shooter, he or she needs to be trained to look for ad hoc weapons such as phones or oxygen regulators, the latter of which can punch through a wall. 

>Treat. This is where a hospital’s response plan differs from a typical shooting scene, Callaway says. A hospital is the place where shooting victims would be treated, so it’s not a site that people can just run away from. After the Columbine shooting and the Boston Marathon bombing, it took police almost three days to clear the scene and sweep for backpacks and secondary devices. 

Get rid of the bling.  

There’s really no place for jewelry in the healthcare workplace. Not only is it a health hazard, as contaminated items can be an infection hazard outside the office, but it can be used as a weapon. Necklaces can be a choking hazard, rings can be a hard weapon, and earrings can be stabbed at someone’s eyes. Instruct your staff to leave the jewelry at home or keep it in a locker. 

Become a bunch of tattletales.  

One of the reasons that accurate statistics on patient violence and worker injuries are not available is that most incidents go unreported. Recent campaigns from nurses’ associations and healthcare worker advocates have encouraged healthcare staff to report incidents to their supervisors and keep good paperwork. Incident reports should always be filled out and kept on file for accurate reporting. 


John Palmer is a contributing writer for PSQH.