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Active shooter training is something to consider after completion of the basic elements of preventing workplace violence.


Hospitals and other health care facilities have fallen victim to violent episodes similar to those plaguing many other areas of society. Indeed, given the stressful situations surrounding many health care visits and the lack of resources for behavioral health and substance abuse treatment, such situations are not that surprising.

Incidents of health care-related workplace violence have been recognized by major regulatory bodies such as the Joint Commission and the Occupational Safety and Health Administration (OSHA) as well as professional societies like the International Association for Healthcare Security & Safety (IAHSS) and the American Nurses Association.

However, hospitals can take many measures to lower the risk of violence directed at staff or other patients. Through proper training and a security-focused approach to technology and space planning, health facilities professionals can help to reduce the potential for violence in their facilities.

Raising awareness

In 1996 and 2004, for instance, OSHA published Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, which was updated again this year. Likewise, the Joint Commission in 2010 published Sentinel Event Alert, Issue 45: Preventing violence in the health care setting. Additionally, OSHA published Field Directive CPL 02-01-052 in September 2011 on “Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents.”

In this directive, OSHA established general policy guidance and procedures for field offices to apply when conducting inspections in response to incidents of workplace violence. The directive also identified health care and late-night retail establishments as the two industries with a high incidence of workplace violence.

Health care workers in general, and emergency department (ED) and mental health staff in particular, face a greater risk of violence than those in most other occupations.

In the 2004 OSHA Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, the agency reported that health care and social service workers accounted for nearly half of all nonfatal injuries reported in the United States from workplace violence and assaults. In fact, the International Council of Nurses noted in a 2009 Nursing Matters fact sheet that “health care workers are more likely to be attacked at work than [are] prison guards and police officers.” If there is any bright spot, it is that health care worker deaths are relatively rare, with the Bureau of Labor Statistics reporting in 2006 that 154 nursing, psychiatric and home health aides suffered fatal injuries from work-related incidents from 1995 to 2004.

Professional associations such as the IAHSS, Emergency Nurses Association, American College of Emergency Physicians and others all have developed position statements and guidelines to assist health care facilities in mitigating violence.

On Feb. 18, for instance, the Joint Commission posted on its leadership blog “Hospital Security — Different Approaches to Mitigate Violence,” which focused on the question of arming hospital security officers. Arming security officers or having police officers on staff certainly are options, but there are many others to consider. Health care facilities should assess carefully all the options as they look to implement reasonable measures to reduce the potential for violence on their campuses.

Causes of violence

The causes of violence in health care facilities are many and varied, but there are some generally recognized factors that contribute to violent incidents:

Increased ED wait times. The stress of waiting for care in sometimes-crowded, tension-filled environments like ED waiting areas has led some patients or family members to lose their tempers and strike out.

Unrestricted movement of the public. Many health care facilities have transitioned to “open visitation,” allowing friends and family to visit any time of the day or night with few limitations. People need to be able to visit their friends and family in the hospital, but there must be reasonable checks and balances in place to limit risks to patients, visitors and staff.

Fewer mental health beds. Most, if not all, states have reduced the number of inpatient beds available for mental health care. The idea was to place these patients into community mental health outpatient programs. However, funding for these programs has been reduced continually since the 1980s, leaving many mental health patients without care and ending up in the ED.

An increase in patient acuity. Many acute and chronic mentally ill patients are being released without follow-up care. These patients have the right to refuse medicine and no longer can be hospitalized involuntarily unless they pose an immediate threat to themselves or others. Often, they turn up in EDs and clinics seeking care in an unstable state.

Increased use of hospitals by law enforcement. Police and criminal justice officials are frequently using hospitals for the care of acutely disturbed, violent individuals or as an alternative to already overcrowded jails.

Lack of financial resources. There is immense pressure to contain costs within health care facilities. This pressure is felt most by non-revenue-producing departments such as security. As a result, some administrators do not want to hear about the need for increased expenses in non-patient care areas.

Reducing the potential

Many health facilities professionals want to consider such initiatives as arming security staff members, metal detectors, staffing with off-duty police or active shooter training and drills. Depending on the circumstances, these may be reasonable and appropriate options.

However, before considering major shifts in preventive or reactive measures, health facilities professionals should first take the following actions:

Conduct a comprehensive evaluation. Reducing the likelihood of a serious incident requires a layered approach involving many aspects of security, including policies, procedures and training as well as physical security and design.

A competent, credentialed hospital security professional should lead this effort using a multidisciplinary team. The local police department may have some resources, but it is much better to have somebody who understands health care.

An assessment of this nature cannot be accomplished through the use of a checklist or online process. These may be helpful, but a combined group including members with knowledge of hospital security and the facility is ideal.

Conduct a workplace violence policy assessment. Evaluate the health care facility’s policy and make sure it has senior leadership support. There are several excellent resources to assist in this process, including OSHA’s Guidelines for Preventing Workplace Violence for Health Care & Social Services Workers and the ASIS International’s Workplace Violence Prevention and Intervention Standard.

Many health care facilities have reasonable policies covering workplace violence, but sometimes they are not utilized even when incidents occur. The workplace violence policy must be evaluated routinely for effectiveness, and measures should be put in place to educate and inform staff of the policy and their role.

Assemble a threat-management team. A threat-management team is part of any good workplace violence program. Comprising representatives from the legal, security, human resources and psychiatry departments as well as local law enforcement and others, depending on the resources, the team must be trained to spot and handle potential threats. Many facilities do not have a threat-management team, but it is an essential element of a workplace violence policy.

Flag dangers in the electronic health record. Develop policies and procedures to identify threatening patients and family members, and patients with violent criminal records.

Patients and family members that previously have threatened or assaulted staff in the past should be identified and flagged so staff members who encounter them in the future have the benefit of that knowledge. This allows staff to take appropriate measures to protect themselves and others.

Some health facilities professionals worry that this may stigmatize patients who previously had exhibited threatening behaviors. This can be avoided if there are reasonable and appropriate policies in place to protect patient privacy.

Design security into new projects. In the next decade, there will be billions of dollars spent on new construction and renovation projects — a major opportunity to build security into each project.

Health care facilities and systems should consider using the IAHSS Security Design Guidelines for Healthcare Facilities and develop systems security requirements that each design project implements as a required part of any new project.

The IAHSS Security Design Guidelines provide guidance to health care security practitioners, architects and building owner representatives involved in the design process to ensure that best practices are considered and integrated into each new and renovated health care facility space where possible.

Train staff. Staff in security-sensitive areas must be trained in crisis intervention and security policies and procedures. Health facilities professionals should evaluate their current crisis training and consider whether it meets their needs in this new era. For instance, active shooter training and response protocols must be assessed and implemented.

Training and technology

The increase in active shooter scenarios, crime numbers and the routine threats hospitals face daily all combine to make security at health care facilities more important than ever.

Whether it’s at a metropolitan hospital, a network of nonprofit health care facilities or a research-based medical center, those responsible for security programs must employ both training and technology to keep their facilities reasonably secure.

Thomas A. Smith, CHPA, CPP, is president of Healthcare Security Consultants Inc., Chapel Hill, N.C. He can be reached at

Planning a response to an active shooter incident

Active shooter incidents are defined as those in which an individual is “actively engaged in killing or attempting to kill people in a confined and populated area,” according to the Department of Homeland Security’s educational booklet "Active Shooter: How to Respond."

Planning for and responding to active shooter incidents are one part of a comprehensive workplace violence program. Health care facilities pose great challenges for those responsible for security when considering active shooter response measures. By design, health care facilities are open public facilities with many unmonitored entrances. Thankfully, active shooter incidents are infrequent in health care facilities, but the potential for a single incident requires all facilities to take reasonable measures to reduce its likelihood and to plan response measures.

There are two primary documents that provide guidance for health care facilities when developing active shooter preventive and response plans. In 2011, the International Association for Health Care Security & Safety (IAHSS) published an active shooter guideline. More recently, the Health & Human Services Office of the Assistant Secretary for Preparedness and Response published “Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans.”

These two documents provide guidance on developing active shooter mitigation and response plans. Some of the basic elements from these two primary resources include:

Utilizing a team to develop the active shooter response plan. A multidisciplinary team should be appointed by the health care facility to designate in writing its plan for responding to an active shooter on campus in coordination with local law enforcement.

Developing specific communication response procedures. Communication procedures should include the creation of a specific announcement, either in emergency code or plain language, and a plan to institute a response to an active shooter situation.

Having a well-functioning emergency alert system. The health care facility should have a timely campuswide notification system to alert staff to the threat of an active shooter. The mechanisms should include multiple modes of notification to reach all persons inside the facility and on its grounds. These may include overhead pages, text messages, digital displays, emails, intercoms, call boxes, pop-up messages, or other methods. These systems should include the immediate notification of local law enforcement.

Identifying potential safe rooms. Facilities professionals should assess each department and identify potential safe rooms to which staff, patients and even visitors can retreat in the event of an immediate threat of danger.

Training employees on handling an event. Employees should be educated on awareness, and their reporting of and response to an active shooter. Procedures should be established for the initial response of staff or anyone in the immediate vicinity of an active shooter. Training should emphasize that each person carry a threefold responsibility: learning the signs of a potentially volatile situation and ways to prevent an incident, learning steps to increase survival of self and others in an active shooter incident, and being prepared to work with law enforcement during the response.



The following references were used by the author in the preparation of this article:

OSHA's Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers

Sentinel Event Alert, Issue 45: Preventing violence in the health care setting

OSHA Field Directive CPL 02-01-052 “Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents”

International Council of Nurses “Nursing Matters” fact sheet, 2009

Bureau of Labor Statistics “Occupational Injuries, Illnesses, and Fatalities among Nursing, Psychiatric, and Home Health Aides, 1995–2004”

Joint Commission Leadership Blog on “Hospital Security – Different Approaches to Mitigate Violence”

ASIS International's Workplace Violence Prevention and Intervention Standard

IAHSS Security Design Guidelines for Healthcare Facilities

Department of Homeland Security's "Active Shooter: How to Respond" educational booklet

IAHSS active shooter guideline

Health & Human Services Office of the Assistant Secretary for Preparedness and Response, “Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans”