Lessons from a tragedy

A tragic shooting, murder and suicide forced risk manager Jeff Natterman to take a long hard look at his hospital’s approach to workplace violence. He told HRMR what he learnt.

September 16, 2010, a normal working day at Johns Hopkins Hospital in Baltimore, was interrupted by the sound of gunfire. Fifty-year-old Paul Warren Pardus, whose mother was recovering from surgery at the hospital, had just shot Dr David Cohen in the stomach. He then walked back into his mother’s room carrying the gun. A sitter who was in the room saw the gun and ran out, slamming the door behind her.

In the corridor, while staff rushed to tend to Cohen, one of them had the presence of mind to barricade the door to Pardus’ mother’s room so that he would find it difficult to come back out into the corridor. From inside the room came the sound of more shots—and then silence.

In the two hours that followed, emergency procedures swung into action. The hospital went into lockdown, and local law enforcement, a special weapons and tactics (SWAT) team and the FBI rushed to attend the scene.
“Everybody remained calm, there wasn’t general panic,” recalls the hospital’s risk manager Jeff Natterman. “We had an active shooter policy and security initiated that policy flawlessly. The security guards knew where they were supposed to go, the local law enforcement set up a command center and hospital security staff were supposed to facilitate that, which they did.

“We had facilities involved to shut down elevators and utilities to make sure he wasn’t going to be able to move far, so within minutes we had pretty much shut down the institution. They also turned off the television in the room so that he would not have information about law enforcement activities.”

The emergency procedures extended far beyond the building in which the incident happened. Traffic had to be re-routed and staff worked with federal and local law enforcement to make the whole area secure in case the gunman decided to fire from the window of his mother’s room. SWAT snipers were positioned on the adjacent building that overlooked the room; security and law enforcement went to all the patient rooms and put crosses on the windows in large tape so that the snipers from across the building could see which rooms had been cleared.

“First and foremost we were concerned about patient safety because we had a whole unit full of patients,” says Natterman. “We had to make sure that those patients were secured because the room was just outside the nursing station. If he had somehow opened the door and started shooting, we had to make sure there was no crossfire that would affect patients or staff.”

Fortunately, there was a second elevator towards the back of the unit which enabled staff to move patients off the unit.

“There were some patients we couldn’t move because transporting them out of their room would have taken them right in the line of fire, so we kept them in place with numerous staff members to barricade the door and make sure they were safe,” he says.

Eventually emergency services got a camera into the room, which confirmed that Pardus was dead, having shot his mother and then himself. Both had died instantly. Dr Cohen went on to make a full recovery and still works at the hospital today.

Post-event analysis

When Dr Cohen was shot he had been attempting to calm Pardus down. It wasn’t the first time Pardus had shown signs of becoming agitated: during his mother’s stay at the hospital he had become known as a slightly unusual character, and staff had been concerned for his wellbeing.

“He presented to the hospital as a bit odd but was not perceived as dangerous,” says Natterman. “A lot of staff speculated about who he was, where he was coming from and there were some general concerns about his wellbeing—in fact, we were taking care of him while he was here visiting his mom. It looked as though he may have been living out of his car and so we were feeding him and offering him clothes and trying to get him some shelter, which he declined.”

While his mother had been in the hospital’s intensive care unit (ICU), Pardus had exhibited some challenging behavior. Staff in the ICU had their own program for ‘de-escalating’ family behaviors, and they employed this to good effect. They found that they could ‘talk him down’ when he got angry, so that rather than having to have him removed they were able to give him support.

“He would generally cooperate once you talked with him and so they thought that for the most part he was a quirky guy who they were able to de-escalate and everything would be fine,” says Natterman.
However, when Pardus’ mother was moved out of intensive care and on to the ward his behavior continued to be troublesome because he was unhappy with her progress. He started inquiring as to who operated on his mother and eventually Dr Cohen tried to explain about the rehabilitation process and the fact that she was actually doing well, although the recovery would take time.

Pardus started to argue with Dr Cohen, who tried to de-escalate his very aggressive behavior, but this time it did not work and Dr Cohen was shot. When analysing events after the fact, Natterman discovered that staff on the ward had been unaware of the difficult behavior Pardus had exhibited in the ICU.

“We learned afterwards that at least one staff member was concerned that he might be suicidal and there was even one person who thought maybe he had a gun,” says Natterman. “The nurses in the ICU were very familiar with his behavior and quirkiness but this, and their suspicions about his behavior, really didn’t get communicated to the nurses on the floor.

“The shooting happened within 24 hours of his mother’s transfer to the ward. When I was investigating the event the nurses on the floor where the shooting happened said they didn’t have a clue that this guy was weird or angry or had quirky behavior. Had the behavioral concerns been better communicated to the floor at least they would have been a little bit more on guard and maybe even would have got security up there sooner.”

After the event the hospital staff had some training from the FBI’s behavioral analysis unit, who gave them a list of the top characteristics to look out for that indicate somebody might be a threat. They found that Pardus’ personality and characteristics hit around 80 percent of the behaviors on the list—but at the time of the shootings nobody in the hospital had the training and knowledge to piece it all together.

There were other lessons too, and it fell to the root cause analysis team to learn them, working through the details of the event in minute detail.

“I had to interview all those folks that were involved and it was like walking on eggshells, trying to be sensitive to what they went through while at the same time trying to get information,” Natterman says. “There was a pretty intense investigation by our department, there were investigations by local regulators, and the occupational health and safety organizations here in Maryland wanted to make sure we had policies, procedures and training relating to workplace violence, which we did.”

ROOT CAUSE ANALYSIS

Natterman and hospital staff had to carry out two root cause analyses, one involved with workplace violence, and a second separate investigation that dealt with the fact that Pardus had complained about his mother’s quality of care.

“We learned a lot on the patient side and also on the workplace violence side of things,” he says.
Some of the main lessons involved communication: the hospital had successfully got word out to staff that they had an active shooter in the hospital using a text message notification system and emails. The area was quickly cordoned off and word spread efficiently throughout the institution. However, staff did not use the overhead speaker system, which was broken at the time.

“Also, we didn’t page 11,000 people because there’s no infrastructure for paging 11,000 people at one time,” he says.

The other communication issue related to the other agencies that came in to help with the emergency.
“It did get a little discombobulated at times because there were so many command centers,” he says. “It would have been better coordinated by having one command center that everybody came to, rather than having three command centers and runners between each of them.”

Another important issue was the panic alarm on the unit itself: staff did not all know where it was and further investigations revealed that some panic alarms in the hospital were not even functioning.

A thorough audit and review of the alarms is just one improvement that has been made since the shootings. Another major change is in the attitude of staff towards workplace violence. As a result of his investigations, Natterman discovered that nurses at Johns Hopkins often failed to report abuse because they saw it as an inevitable part of their job.

“What we routinely heard was that they had taken one on the chin for the institution because there was this cultural aspect of being a nurse here which said you just had to deal with violent behavior. That was very upsetting to a lot of us in risk management leadership because nurses have rights too and they don’t have to take abusive behavior from patients—there are ways of dealing with that.

“After the shooting we trained them that if a patient is abusive or violent or threatening then you have to say something about that, you can’t just suck it up—and I’m very happy to say that after the fact we have pretty much zero tolerance for abusive threatening behavior.”

LEARNING AND CHANGING

The hospital now has a new behavioral alert system whereby threatening or abusive behavior from a patient or his or her family members gets put into that patient’s medical records. This means that even if a patient is re-admitted at a future date, staff will be on guard and can put safeguards in place, from calling security to making sure the patient is in a certain room.

This initiative is further supported by the introduction of security contracts, which are implemented if there is any inkling of trouble from a patient or hospital visitors.

“Security will come and sit down with those people and tell them what the rules and regulations are and what the consequences are of their behavior, and then have them sign a security contract,” says Natterman. “It might lead up to barring them from the hospital.

“Since the shooting incident in 2010 we’ve implemented 23 security contracts—so it’s not like we have bedlam here at Hopkins: we have a million patient contact hours a year but we’ve had only 18 security contracts placed in two years. The same goes with the behavioral alerts—since we instituted the  system here we’ve put in only about 32 alerts.

“We’ve also added to our patient and visitor handbook the rules about behavior and we’re very clear upfront that we take threatening and abusive behavior very seriously, and it can result in being discharged or termination.”

One of the most important changes implemented by the hospital is the introduction of its new clinical customer services coordinator program. Investigations revealed that a lot of problem behavior stemmed from little things that were not addressed or taken care of in good time. That led to frustration for patients and their families, sometimes to the point where they became violent or threatening. In order to address this issue the hospital has hired a team of staff to look after clinical customer service in each of the units.

“Their sole responsibility is to work out problems like parking, food, communication or setting up appointments—whatever it takes to get the care coordinated better,” says Natterman. “They are also the frontline for original grievances and helping to resolve those grievances instead of having it go to some centralized grievance group that then deals with it with less alacrity. By addressing these concerns in real time we’ve seen a statistically significant drop in the kinds of complaints that we see in our patient relations department or to the legal department.”

Tragic though the events of 2010 were, they could have been a lot worse. The quick thinking and emergency procedures implemented by the staff meant that even if Pardus had tried to move about the hospital, he would not have got far. Some important positives have come out of the incident, especially in terms of improved customer service and the zero tolerance of violence towards staff.

It’s to his credit that Natterman is willing to talk about the lessons learnt, in the hope that similar tragedies can be prevented at hospitals throughout the US. To date, he has lectured twice nationally on the topic; wherever he goes he finds that other risk managers report similar issues.

“It’s amazing how many people have come up to me after the lecture telling me their own stories and they’re really where we were before the shooting,” he says. “They haven’t had an incident yet, or maybe they had some bad incidents but nothing as bad as a shooting, a murder and a suicide. It’s astounding to me how much this issue is under the radar screen.

“Other people are talking about it in the underground but it doesn’t surface until you’ve had a really tragic incident. I think a lot of hospitals don’t feel certain about what to do: they’re doing what we did until 2010. We were organized but untested, like everybody else—and even with the changes we’ve made we’re still vulnerable to terrorism, to random attacks. Hospitals are vulnerable places but I think we’re in a better position now to mitigate some of that potential harm.” 