Quick Safety 4: Preparing for active shooter situations (Updated June 2021)

Update: June 2021

Issue:

It is an unfortunate fact that gun violence occurs in health care facilities. During the 2010-2020 timeframe, The Joint Commission received reports from its accredited organizations of 39 shootings that resulted in 39 deaths: 21 were staff members (10 shot by a patient, five shot by a visitor, four shot by a family member, and two shot by a current or former staff member); 18 were patients (15 shot by a family member; two shot by a visitor; and one shot by another patient). Of the 39 shootings, 12 were murder/suicides, mostly mercy killings that resulted in the deaths of the patient and the shooter, who was usually the patient’s spouse or significant other; other “suicide” deaths resulted from provocation with security (“suicide by cop”). These cases involve an “active shooter,” an individual actively engaged in killing or attempting to kill people in a confined and populated area. Victims of an active shooter can be randomly selected, and often are health care staff.

Active shooter situations are unpredictable and evolve quickly. Typically, the immediate deployment of law enforcement is required to stop the shooting and mitigate harm. Because active shooter situations are often over within 15 minutes, before law enforcement arrives, health care organizations must prepare their staff for an active shooter situation.

Safety Actions to Consider:

Since every health care organization is different because of its patient population, location, size and other variables, health care settings present a unique set of challenges when planning for active shooters. Planning should take into consideration what works best for each organization’s particular circumstances. Below are some strategies that organizations can use to help be prepared for active shooter events.

Involve local law enforcement in your plans.

• Meet with law enforcement now, prior to an event, to discuss your organization’s plan.
• Develop a plan to assist law enforcement, if you have access control (controlling access and egress to the building or area) in place to determine how they will be able to move about your organization.
• Make law enforcement familiar with your building and the location of your Incident Command (IC) center and back up location. Provide them with life safety drawings (electronic and hard copy).  
• Find out who the law enforcement liaison officer is for your organization. It is critical that the officer knows who to contact at your organization, and how to communicate with them.  

Develop a communication plan.

• Establish a primary communication method with local law enforcement, such as a police radio in dispatch. 
• Establish an emergency hotline with a recorded message for employees. Make sure employees know the hotline number and the phone number of local law enforcement.
• Develop a “script” that can be used by those in the IC center to respond to calls from family members about an incident.
• Have your organization’s press/public information officer join the regional or county Public Information Officers (PIO) group to facilitate information sharing. If there is no local PIO group, establish one.

Assess and prepare your building.

• Develop processes and procedures to “lock down” your building and prohibit walk-in traffic (including any dedicated employee entrance) at the onset of an event.

Establish processes and procedures to ensure patient and employee safety.

• Determine how to account for employees and patients during an incident.
• Determine how to handle critical patients during an event. In the case of evacuation, you may need a police escort for these patients.
• Hospitals should take into consideration the loss of services and access to critical operations for up to 10 hours following an event. The hospital and any adjacent space becomes a crime scene. 

Train and drill employees.

• Provide ongoing training for all employees, including:
• How to report and respond to active shooter events
• What to expect when law enforcement arrives
• How to protect patients
• Awareness of high-risk security sensitive areas (such as the emergency department, operating rooms and pharmacy), and how to implement mitigation strategies
• Conduct IC support training for security personnel, “house supervisors,” leadership, and other employees who need to be aware of, or involved in, IC support during an incident. 
• Conduct periodic drills or “tabletop” exercises to prepare employees for an active shooter event. If drills are conducted, inform patients and visitors of the drill so they will not be alarmed, or hold the event in a section of the building that is no longer in use or occupied.

Plan for post-event activities.

• Conduct debriefings.
• Identify and manage anxiety or fear among patients, staff, and leaders. This may manifest immediately, or in the days and weeks after the incident. Use behavioral health resources, your organization’s Employee Assistance Program (EAP) or chaplaincy, as needed.

Resources:

• International Association of Emergency Medical Services Chiefs: Healthcare & Public Health Sector Coordinating Council. 2017 Active Shooter Planning and Response: Learn How to Survive a Shooting Event in a Healthcare Setting. Washington, DC. Jan. 24, 2017. Covers ethical considerations, prevention and preparation, assessment teams, response plans, law enforcement tactics, initial response, special areas for consideration (such as the emergency department), and victim/family member services.
• California Hospital Association: Emergency Preparedness: Planning for Active Shooter Incidents webpage. A variety of resources for hospitals, including CHA’s Active Shooter Planning Checklist, and a training video from the U.S. Department of Homeland Security.
• Ready.gov website: Attacks in Crowded and Public Spaces. Information on steps to take to prepare, protect and help others in the event of a mass attack. 
• U.S. Department of Justice: FBI.gov website. Active Shooter Resources. Includes training videos and law enforcement information.
• The Joint Commission’s Workplace Violence Prevention Resources Portal

Note: This is not an all-inclusive list. 

Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert. The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations. The information in this publication is derived from actual events that occur in health care.

©The Joint Commission, Division of Health Care Improvement