Planning for the Unthinkable … Healthcare Response to Armed Violent Intruders

By Mike Murray, Mitigation Dynamics Institute
When my colleagues and I first entered into the world of healthcare consulting several years ago, we were shocked at the frequency of violence. Among other things, we discovered that 1 out of every 9 ED nurses were the victims of assault every week. In addition to being punched, grabbed, pushed or slapped; domestic assaults, sex offenses and even shootings were not uncommon. While digesting this, we thought to ourselves … If healthcare was ever considered a “safe haven” by society, this perception must certainly be in jeopardy now.

Despite our extensive law enforcement experience, it was fair to say that the initial data related to that violence truly shocked our conscience. As a result, we were instantaneously compelled to make a difference … a difference we continue to make today.

In 2014 there were over 70 incidents involving armed violent intruders in the United States. This translates to an incident occurring every 4 to 6 days. At Mitigation Dynamics, Inc. (MDI), we define an “armed violent intruder” as a person on hospital property with the means (weapon), opportunity (patients, visitors, physicians and staff) and apparent intent (thought process) to inflict serious physical injury or death to others.

MDI classifies these incidents as “low propensity, high consequence.” Once an armed violent intruder fires the first shot, second’s count … and the consequences shock the conscious.
• The armed violent intruder at Virginia Tech University murdered 32 people and wounded 25 others within 7 minutes …
• The armed violent intruder at the movie theater in Aurora, Colorado murdered 12 people and wounded 58 others within 5 minutes…
• The armed violent intruder at Sandy Hook Elementary School murdered 26 people and wounded 2 others within minutes…
• Collectively these incidents equate to a murder attempt every 6-10 seconds…

It is not likely that armed violent intruder incidents will stop in the near future. However, we know that with the implementation of an effective policy, comprehensive training and the utilization of scenario-based drills, a hospital and the staff within, can drastically minimize the overall effects of these incidents.

Large open areas, easy access, security limitations, and multiple potential victims all culminate to make a hospital an “easy target”. How a hospital responds to a crisis such as this, is dependent upon how well that organization has prepared. What will you do? … How will you respond? … What guidance will you provide?

Ironically, few hospitals have comprehensive, realistic and practical policy or procedures related to an armed violent intruder response (active shooter). Furthermore, most of the policies in place would not withstand professional scrutiny should an incident occur. To be clear, we have yet to encounter intentional dismissiveness as it relates. On the contrary, these circumstances are typically a product of misinformation or a false sense of reality.

Effective policy:

MDI strongly recommends that hospitals establish and utilize principally based policy and procedures. Policies that consist of “always” and “never” are destined to fail under dynamic circumstances, such as an active shooter. Similarly, procedures that consist of “if this than that” verbiage are also problematic.

Principally based policy and procedures create the opportunity for an organization to provide “personal tools” to their staff. This ultimately provides empowerment for them to make their own individual decisions based on the totality of circumstances they are confronted with, while maintaining the spirit of the organizations policy.

Various alluring templates are available on the market; however, there is no such thing as a “one size fits all” solution. This further supports the necessity for organizations to employ principally based doctrine. Consulting with qualified risk professionals provides opportunities to create or evaluate existing policy and procedures. All of which, should be designed to meet the particular needs of your facility, while enhancing employee engagement, limiting liability and creating a safe environment for all patients, visitors, physicians and staff.

To be clear, policy and procedures can and should dictate certain aspects of a response. For example, in the event of an armed violent intruder occurrence, should an overhead announcement be made? If so, should the TJC recommended “Code Silver” be utilized, or would simple plain language be more appropriate? Perhaps a combination of both should be considered.

Simply put, policy and procedure should allow for individual decision-making, ultimately empowering staff to evaluate, process, and decide what the best response is for their particular circumstance.

Comprehensive Training:
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It has been said that “any training is better than no training”. To the contrary, it is our professional opinion that training specifically related to high consequence, life threatening events are certainly worthy of a vetting process. Topics such as response to an active shooter require specialty training. Training that, in addition to general concepts such as “Run” or “Hide”, also provide principally based, personal tools for the healthcare professional. Principles and tools that have proven to work effectively time and time again under dynamic circumstances.

Conceptually, each employee of each hospital, should be exposed to consistent, comprehensive training that encompasses how personal tools learned from that training are supported by the relative policy, such as response to an active shooter. Ideally, this would also allow for an interactive discussion between the trainers and attendees, as well as facilitate additional comprehension, retention and over-all confidence in the prescribed process. Additionally, the training should be able to be delivered effectively via various platforms such as lecture, classroom, web or scenario based solutions.

Scenario Based Drills:

It’s safe to say that your favorite professional sports team is not simply handed a play book to read, then expected to perform effectively on the following game day. The same can be said for your organizational team (staff). Yet, if we’re honest … we often times disseminate policy, ask our staff to “read it, and sign off on it.” While unintentional, this type of “check the box” practice unnecessarily creates the formula for operational failure, financial liability and damaged reputation.

In conjunction with well-written policies and quality training, every facility should conduct annual scenario based drill(s) to ensure that all employees understand what their individual response protocol would be in the event of an active shooting event. These drills can be large or small, or even in the form of a tabletop type exercise depending on the specific needs of the hospital.

Conducting these types of drills in areas specific to the attendees, allow for observation, discussion, review and understanding of the appropriate actions and response during an active shooter event. This also allows for each of the attendees to envision what their individual response or subsequent actions might be, which has proven to be both empowering and engaging, all the while having the policy “come alive” and have special meaning for the attendees.

It is an indisputable fact that the threat of active violence within the healthcare setting is ever present on a daily basis. However, with the implementation of effective policy / protocols, the utilization of comprehensive training and scenario based drills; your staff will be prepared for the “unthinkable”. After all … seconds save lives!


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