Preparing for the 
threat of violence


Preparing for the 
threat of violence

In the event of an active shooter incident healthcare facilities may find themselves legally liable for negligence because they failed to implement a security plan, provide training, or take appropriate actions. Michelle Foster Earle, president of OmniSure Consulting Group, explains what can be done.

Bessie Jones was a longtime nursing home resident with failing health. Her son visited her sporadically. When he did visit, staff observed that he was somewhat disruptive. He tended to be loud and demanding when he believed that his mother’s needs were not being met. 

During one of his visits, he observed that her legs “didn’t look good”. When a member of his mother’s care team tried to explain the condition that was causing the swelling and discoloration in his mother’s legs and the reason for a delay in starting the medication the doctor ordered, he became angry and said “I’m coming back tomorrow and if her legs aren’t better, someone’s going to pay. I’ve done hard time and I don’t mind doing it again if that’s what it takes to get you all to take care of my mother.”

Increases in fatal incidents such as the shooting at Brigham and Women’s Hospital reinforce the need for healthcare facilities’ disaster preparedness and emergency operation plans to include threats, acts of violence, and active shooter incident planning. 

When preparing for aggressive acts, especially an active shooter incident, step one in an effective plan is prevention. A good place to start is with a security risk assessment by a qualified expert who will determine what the vulnerabilities are and make recommendations to reduce risk. 

This type of assessment is more than just hiring a security company to assess the entrances, physical layout and need for security cameras. It’s important to include an assessment of the specific healthcare services provided and the types of patients served to determine the potential triggers. Are services acute or long term? Are visiting family members especially vulnerable to feelings of helplessness or despair? Are mental and behavioral health services offered? Are there socio-economic, racial tension, or ethnic factors to consider? 

A thorough assessment takes all of these factors into consideration to evaluate possible workplace violence and security liability risk exposures and then makes recommendations for improvements that will reduce risk. 

For example, OmniSure was called in by a continuing care retirement community after a male resident in independent living fatally assaulted another male resident who was reportedly pursuing a romantic or sexual relationship with him. An assessment revealed that the resident who killed his pursuer believed he was defending himself. Further investigation revealed he had been incarcerated as a young adult and may have been sexually assaulted at that time. 

Our risk assessments in a number of settings from senior living to behavioral health to youth residential treatment will often determine the need for better screening of applicants seeking care or residence. The resulting recommendation is that the intake process includes an assessment of the patient’s/client’s/resident’s psychosocial needs, asking about trauma, past and present mental health concerns, criminal history, sexual abuse or misconduct, and other factors affecting the likelihood of aggression or risk of victimization.

Protection is the ultimate goal and depending on the setting, there are a number of different measures that can be taken. Measures might include signs prohibiting firearms, metal detectors, security cameras, panic alarms, and restricted access. The most important weapons against violence, however, are (1) training, (2) training, and (3) training. 

It’s easy for busy healthcare professionals to become complacent about their physical safety in a caring environment. No-one ever thinks it will happen to them but according to the Bureau of Labor Statistics Census of Fatal Occupational Injuries (CFOI), in 2012 the labor industry experienced 475 homicides in the workplace; 381 occurred from being shot intentionally by another person.  

Homicide is the leading cause of death for women in the workplace. Employees need to know their role if there is an event and what to do. Drills are essential. Hospitals with proactive programs often enlist the resources of community-based police departments and emergency response teams who have exceptional skills and response training. Collaborative drills can strengthen reaction skills, test communication systems, and help identify areas which need honing.

Be prepared

Training should start as soon as employees are hired by implementing a workplace violence prevention training program that is part of the formal orientation process. The same training should also be provided to current employees. It’s recommended that all security staff job descriptions and employment requirements contain formalized training criteria, physical job descriptions and continued education requirements. 

At a fundamental level, healthcare facilities should ensure that policies and procedures address all aspects of operations with regard to violence prevention, training, education, screening, reporting, responding, investigation, discipline, monitoring and review processes.

Mitigation: Train staff in de-escalation, using programs created by formal training organizations committed to best practices and safe behavior management methods that focus on prevention. 

Review resources such as the 2012 edition of Active Shooter: Recommendations and Analysis for Risk Mitigation. distributed by the California Hospital Association.  

Response: In an incident such as an active shooter, employees need to remember and act on a three-part plan, recommended by the FBI Critical Incident Response Group—Run. Hide. Fight. Surviving an Active Shooter Event. Drills to practice this response are essential. The FBI has released a video that can be helpful in training staff and implementing drills on a regular basis.

Recovery: Healthcare facilities need a crisis communications plan that includes staff, patients, visitors, law enforcement agencies, and the media (don’t forget social media). Know when to say “all clear” and who it is that says it. After an incident, it’s critical to have a plan for those affected. Not just immediate emergency medical care, but ongoing support and counseling as well.  

Without taking these steps, healthcare facilities may find themselves legally liable in the event of an active shooter incident for negligence because they failed to implement a security plan, provide training, or take appropriate actions to prevent, protect, and respond.

Michelle Foster Earleis the president of OmniSure Consulting Group, a risk management firm contracted by some of the nation’s leading medical professional liability insurance companies to help medical practices, hospitals, healthcare facilities and providers of healthcare and social services nationwide reduce risk, improve performance and avoid lawsuits. She has earned designations in healthcare management, is licensed general lines property and casualty agent in Texas, and is an associate in risk management. She can be contacted at: 

Michelle Foster Earle, Omnisure Consulting Group, Insurance, Risk Management, US, Crisis management