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Your action plan: What to do when violence strikes


January 1, 2018

Experts say you should have a plan in place and practice it. Consider this your guide for training and planning.

Editor’s note: This is the first of a series of stories that will help address the need for medical clinics to have a plan in place when certain emergencies occur. Use the tips in these stories to create your own protocols and to help during employee training.

By now, the advice has been loud and clear to safety folks and administrators of medical clinics: You should have a safety plan in place that addresses the possibility of an agitated patient in your facility, or, at worst, a violent intruder or active shooter.

The reality is that healthcare facilities are increasingly becoming the target of armed violence. Usually, it’s the result of an anxious or disgruntled patient—angry at a large medical bill, perhaps, or someone nervous about upcoming treatment. More frequently, however, armed incidents are carried out by upset spouses who go looking for their estranged partners at work, or by an angry family member who blames the illness or death of a loved one on a physician.

In a hospital, there’s usually several layers of protection, including locked doors, security forces, and trained employees who know how to de-escalate a situation. That’s not always the case in clinics. You can still walk unimpeded into many medical facilities and be greeted by staff at an open desk in an open waiting room. It’s an environment that leaves staff and patients vulnerable to acts of violence.

Take the situation of November 27, 2015 in Colorado Springs, Colorado. In that case, Robert Lewis Dear Jr., a 57-year-old man from Charleston, South Carolina, targeted the Planned Parenthood clinic there based on his religious and political views against abortion.

Dear entered the facility after firing several shots outside, according to published reports, and took several staff members and clients hostage during a five-hour standoff with police. At the end of the incident, SWAT teams stormed the clinic, resulting in Dear’s arrest, but not before one police officer and two civilians were killed.

What would you do if that was your clinic? How would your staff react? What steps would immediately be taken to shut down the clinic, contain the situation, and ensure the safety of your patients? What are your protocols to communicate with responders?

Many healthcare experts suggest that during the holidays, healthcare facilities should take a close look at their violence prevention plans, practice response plans with employees, and take extra precautions to shore up their facility’s physical environment. Consider this article your guide to help you plan your actions and train your employees.

Before violence occurs

Secure your facility. This could be one of the most important factors in determining whether or not there will be a violent incident in your facility. Of course, if the violence is caused by a patient who is already inside, you’ll have to switch to Plan B, but keeping a violent person outside (or at least slowing the person down) should be your first priority.

Unfortunately, many clinics still don’t have even the most basic of security measures to protect them. At the very least, exterior doors should latch when closed, and interior doors leading to patient care areas, as well as doors in the back of the facility, should always lock when closed.

Quick design advice: Front desk staff are especially vulnerable and are likely to be the first point of contact in a violent confrontation. They should greet visitors warmly, but always behind a glass or hardened plastic (preferably bulletproof) partition. Install a button behind the front desk to quickly lock or unlock the doors, as well as a panic button to alert other staff of any safety problems.

Training tip: Instruct your personnel to make sure they always keep doors shut and to always check that doors are locked behind them; this can pose a major problem during warmer weather when staff may be tempted to open some back doors and let the fresh air in.

Learn to be calm. Staying calm and collected can keep a situation from escalating out of control. Staff in hospitals regularly go through de-escalation training that helps neutralize a situation; options for doing so range from quietly talking and empathizing with an individual to physical restraints that can buy time until police arrive.

Quick design advice: How calm is the environment in your waiting room? If you were a nervous patient waiting for a procedure, would you feel welcome there? Would the staff seem inviting? Take a look around your facility from the perspective of your visitors, and make some quick changes where necessary. Comfortable furniture, some quiet music, a paint job in a different color, or a coffee maker can make a huge difference.

Training tip: In your next in-service training, play make-believe regarding de-escalation techniques. There are many resources on the internet, or you could ask a police officer to come in and train your staff in some of the basics. Have your staff role-play, taking turns talking to each other and using calming language to show empathy and help keep anxious people from turning violent.

Detect the warning signs. To avoid having to put de-escalation tactics into play, you should first be able to identify when something is about to happen. Healthcare security experts say that nonverbal and body language are the first cues to look for when detecting potential violence. Look for changes in a person’s voice or demeanor—someone who suddenly becomes too quiet, or a smile that turns into a frown. Also, if a conversation about a medical bill at the front desk suddenly leads to a raised voice or clenched fists, these can be clear and easy signs that violence may be close behind. It’s time to calm the situation down.

Quick design advice: Make sure that wherever there is interaction with visitors, staff are not alone. While you want patients to feel comfortable, they should know that they will have people observing their actions. That alone could serve as a deterrent; plus, it ensures that if a problem is about to escalate, someone will be able to step in if need be.

Training tip: Have your staff observe people in the environment and notice the signs of someone who is nervous, agitated, or otherwise upset. Contrast this with how the person looks and acts while calm. You’d be surprised what you notice when you are actively looking.

Call the police. The time to make first contact with your local law enforcement officials should not be when you need them the most. Hospitals and many healthcare facilities have ongoing relationships with police and fire officials to train and plan together. Make sure they know the floor plan and access points of your building. Plus, having a police officer who visits once in a while can serve as a good deterrent.

Quick design advice: Make sure you know the easiest way for law enforcement to enter if necessary—and that may be inside the door of a main building. Map the entrances and exits, and prepare a written copy of this map for the local police chief. If the door in question is locked, supply the key or keypad code to save precious moments in an emergency.

Training tip: This one’s easy. Invite a police officer in for a snack or donuts and coffee during your next in-service session. Let your staff meet your local first responder. There is nothing more important than face time with those you may need to work with in an emergency.

During violent incidents

Hide in pre-designated areas. You won’t be able to prevent everything. In the event that an armed person introduces a weapon into the situation, your first priority will be to protect yourself and your patients from further harm. Security experts recommend the “run, hide, fight” protocol, which instructs people to run from a situation and out of the attacker’s line of sight, only fighting back as a last resort. In most violent situations, the incident is over quickly, and casualties are minimized when the attacker has no one to attack.

This being healthcare, workers are trained not to leave patients behind. There should be a designated room where staff and patients can go to escape, especially in smaller clinics where there isn’t a lot of space. Staff in hospitals are trained to run, look for a room they can barricade themselves in, and lock the door to keep violent individuals out. Give your employees a fighting chance by designating such a safe room, or at least a place outside they can run to—perhaps a neighboring office in your complex.

Quick design advice: Where can people hide in your facility? Identify quickly accessible rooms with a locking door—extra points if that room has a second door that leads to an isolated hallway or the outdoors where an escape route (or rescue) is possible.

Training tip: Take a few minutes to see how fast your staff can get into the safe room, or grab a few patients and evacuate. Practice an active shooter drill, like schools do, and learn how to become invisible: Don’t hide near windows or give an attacker a clear line of sight.

Ensure clear communication. If violence breaks out in your clinic, the best thing you can do to end it is to get help there as quickly as possible. When the police arrive, they are going to want to know what’s going on and what they are facing. The more information you can give them, the better.

Quick design advice: Consider how your staff communicates with each other. Is there a panic button at the front desk that can alert staff in the back to a violent situation? What if the phones aren’t working? Staff members, or at least supervisors, should consider wearing portable radios for communication, especially if someone happens to be outside the building. Remember that meeting with the police? Now’s the time to give them one of those portable radios so they can keep in contact with people inside.

Training tip: Practice your emergency communications, especially any codes or alert words to inform fellow staff that something is going down. There should always be a meeting point established (perhaps in the parking lot), so that staff can meet if an evacuation is necessary and a head count can be conducted.

Fight only if necessary. In most cases, the best thing to do when dealing with an armed intruder is to run or hide. But if healthcare workers come face to face with the intruder, they may have no choice but to fight back to protect themselves and their patients—and hopefully provide an opportunity to escape.

Quick design advice: Identify “weapons of opportunity” in your facility. These are objects that can be used—either by an intruder or your staff—in a violent situation. Some facilities have rooms with doors or cabinets that will pull down to hide sharp instruments and other items that can be used as weapons.

Training tip: Teach your staff that they should always seek to leave the building or hide in place if there is an armed altercation. If they need to fight, they should do so quickly and with the intent to stun or incapacitate the attacker long enough to give them an opportunity to escape. Oxygen tanks, IV poles, and even broken glass or a chair can be used as weapons. Consider inviting a martial arts or police tactics instructor to teach techniques that can help workers escape a situation.

After a violent incident

Listen to the good guys. You are in the business of saving lives. But if a violent situation involves law enforcement or the fire department, they will take over the situation to both neutralize any suspects and handle investigation of the situation. You will need to prepare your staff and facility to defer to the authorities after a violent event.

Quick design advice: Do you know where your records are stored? Police will need access to files, especially if the situation involves a patient. Do you know where your SDS files are for hazardous chemicals? You’ll need them if there is a fire, explosion, or chemical exposure—knowing where they are is an OSHA requirement.

Training tip: First, teach your staff where the SDSs are kept. OSHA will check during an inspection to make sure they know. Next, teach them that working with authorities will be paramount after an incident. Staff should do what they can to protect any evidence, which means they should put on gloves, stay away from any weapons, and quickly and orderly evacuate patients.

Debrief your staff as soon as possible. Your staff will be rattled after a violent incident, and they will need to be taken care of. Once the incident is over and the police have left, shut down the facility and take some time to sit with your staff and talk about what happened. If anyone needs counseling or first aid, make sure they receive it immediately.

Quick design advice: There’s not much you can do from a facility improvement standpoint when it comes to aftercare, but you certainly can make it easier for your workers to seek help. There should be a form and an anonymous system in place for staff to request aid after an incident, especially if they feel they are suffering from post-traumatic stress disorder.

Training tip: Teach your staff that their mental and physical health is always the most important thing. Institute a wellness program that encourages good nutrition, stress reduction, and regular sleep. Recruiting a counselor to come in and teach about the signs of post-traumatic stress disorder is also a good idea.

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