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Do you know what to do if there's an active shooter where you work?​​​​​

Incidents such as the mass shooting at an elementary school in Newtown, Connecticut have prompted individuals and organizations, including hospitals and other healthcare facilities, to consider response plans for an “active shooter,” defined by the U.S. Department of Homeland Security as “an individual actively engaged in killing or attempting to kill people in a confined and populated area, typically through the use of firearms.” Does your workplace have a plan in place for how to handle an active shooter? Would you know how to react to protect yourself and your patients or clients? 

A rare but deadly problem
A 2012 Johns Hopkins’ study published in Annals of Emergency Medicine found 154 hospital-related shootings occurred from 2000 to 2011, with 91 occurring inside the hospital and 63 outside on hospital grounds. Although rare, these shootings can be deadly, particularly to the perpetrator, who was the victim in nearly half (45%) of cases. Nurse and physician victims accounted for 5% and 3%, respectively. 

Most perpetrators (91%) were men, and motivations included grudge, suicide, euthanizing an ill relative, and prisoner escape. Keep in mind, however, that according to the U.S. Department of Homeland Security, active shooters typically have no pattern or method for selecting their victims.

Healthcare facilities at risk
Most healthcare facilities are open to the public, sometimes at unusual hours, making it relatively easy for a shooter to gain access. Your may also be seeing increasing numbers of seriously mentally ill patients because of reductions in community psychiatric resources. Depending on the set up of your facility, you may want to consider extra security precautions, such as conducting bag checks. 

The challenge is that shooting events are unpredictable and difficult to prevent. But, that doesn't mean you can’t try and that you can’t be prepared to react if a shooting incident occurs where you work.

Be prepared
An active shooter could be an employee, a patient or client, a physician, or someone else. Be alert to people acting suspiciously, such as appearing nervous when you ask simple questions. Some people may exhibit signs of potentially violent behavior such as depression or withdrawal, repeated violations of your facility’s policies, explosive outburst of anger, unexplained increase in absenteeism, decrease in attention to appearance and hygiene, and talk of severe financial problems or previous incidents of violence. Report any concerns to your manager and, in the case of patients or clients, document your objective observations in the medical record. 

It’s important to know that in January 2013, the Department of Health & Human Services released a letter to healthcare providers saying that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule “does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people.” The letter recommends clinicians be aware of state laws related to disclosure of patient information to prevent or lessen the risk of harm. 

Don’t be afraid to ask for security presence if you suspect a patient or client has the potential for violence. Your facility may want to consider closed circuit monitoring and should ensure sufficient lighting exists. Be sure your facility has a zero tolerance policy, which has ben found to reduce the numbers of violent incidents.

An active shooting is typically over within 10 to 15 minutes, so advanced preparation on how to react is essential. Ensure that your facility has an emergency plan that covers active shooters and includes areas of responsibilities, emergency phone numbers, and response plans. If it doesn’t, volunteer to help create one. Facilities should review crime statistics for their area and involve employees to identify areas needing more security. The Emergency Nurses Association developed an algorithm for mitigating violence; although hospital-focused, it has several principles that may be helpful in clinic settings. Visit for more information.

It’s best to have a code specific to this situation, such as “Code Silver” or “Code Gray.” This prevents people rushing to the scene to “help” and instead being put in harms way when a code designed to alert others to violent patients is used.

Communication can be particularly challenging in these situations, so it’s important to set up a command center and to establish clear lines of communication, including how to notify people when the crisis is over. In some cases social media may be appropriate for public updates.

You should participate in training exercises, which are the most effective means for preparing you. In the training you will likely learn how to recognize the sound of gunshots, how to react, and how to adopt a survival mind set. Ideally, security in your clinic and local law enforcement will participate in the training. Participation should be documented in the employee’s education record.

Consider what to do
The U.S. Department of Homeland Security offers these suggestions for responding when an active shooter is in your area: 

Evacuate. Exit if there is an accessible escape route. Leave your belongings behind and try to help others escape. Keep your hands visible so law enforcement can see you are unarmed.

Hide. If you can’t get out, find a place to hide. Block entry to your hiding place if possible, for example, by pushing furniture against the door. Silence your cell phone or pager and turn off any other sources of noise such as a radio or television. 

Take action. As a last resort, and only if your life is in imminent danger, try to incapacitate the shooter. Find a makeshift weapon and act aggressively: yell and throw items. Try to remain calm, particularly if you are with patients or clients at the time. When you contact 9-1-1, give the location of the shooter, the number of shooters, a physical description, number or type of weapons, and number of potential victims. When law enforcement or security arrives, follow their orders, knowing that they may shout commands and use pepper spray or tear gas. Employees not in the area can take actions such as ensuring that emergency vehicles are diverted from the facility, securing elevators to limit the shooter’s access to other floors, and monitoring and reassuring patients and others who may be aware of what is happening. 

Tap into resources
Several resources are available to help you learn more about responding to an active shooter: 

Hospital Code Silver Activation: Active Shooter Planning Checklist. Developed by the California Hospital Association, with input from agencies such as FEMA, U.S. Department of Homeland Security, and the International Association for Healthcare Security and Safety, this checklist covers several components including: mitigation, preparedness, response and recovery. Although designed for hospitals, it can be useful for other healthcare faclities. Download a copy at

Videos and webinar. Several training videos and a webinar are located at​.

Active Shooter: What You Can Do. This free interactive web-based course from FEMA provides guidance for individuals. Visit for more information.

U.S. Department of Homeland Security. This department published Active Shooter: How to Respond booklet as well as a pocket card with key information. Both are available in English and Spanish. You can access these, as well as a webinar and other resources, at

Thinking ahead 
Clinicians—and our patients or clients—could easily be in the line of fire should an active shooter enter your healthcare facility. By being prepared and alert, you can help mitigate a tragic situation. 

Cynthia Saver, MS, RN, President, CLS Development, Columbia, Maryland.


California Hospital Association. Hospital code silver activation: Active shooter planning checklist. 2012. Available for download at 

Department of Health & Human Services. Message to Our Nation’s Health Care Providers. January 15, 2013. 

Emergency Nurses Association. Violence mitigation: Concept to implementation algorithm. 

Howell WLJ. Violence in hospitals. Hospitals & Health Networks.

Kelen GD, Catlett CL, Kubit JG, Hsieh Y. Hospital-based shootings in the United States: 2000 to 2011. Ann Emerg Med. 2012;60:790-798. 

U.S. Department of Homeland Security. Active Shooter: How to Respond. 2008.
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