Active Shooter – How Healthcare Facilities Can Prepare for the Worst

By November 23, 2018 No Comments

Active shooter incidents across the country, like the ones that recently occurred at Tree of Life Synagogue in Pittsburgh and Mercy Hospital in Chicago, strike fear into the hearts of everyone. With a seemingly increasing frequency of occurrence, there are some actions to take that can help us prepare.

According to the Occupational Safety and Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occurred in healthcare and social service settings. Further, workers in healthcare settings are four times more likely to be victimized than workers in private industry. Active shooters are an increasing threat to healthcare workers, and given that patients may not be able to evacuate, planning for an attack presents extra challenges.

The U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Justice, FBI, and FEMA, issued a joint document in 2014 that advises the healthcare industry on preparing for an active shooter incident. Below are three essential principles for creating an active shooter plan:

Evacuation and Lockdown 

Evacuation is the safest bet during an active shooter situation, however, mobility or the lack thereof, must be considered in these plans. The DHS et al document identifies people with vision and/or hearing impairment, intellectual disabilities, children, and the bed-bound as particularly vulnerable when evacuation is necessary. Recommendations to protect this cohort include:

  • Creating access points when elevators are not functioning (similar to a fire drill).
  • Identifying “shelter in place” areas for those who cannot get out.
  • “Shelter in place” areas should have ballistic protection known as “cover,” which includes thick walls made of steel, cinder block or brick, solid locking doors, and minimal glass or interior windows. It is also a good idea to have emergency kits in these areas to control hemorrhaging from gunshots or more minor injuries.
  • Training staff in “Psychological First Aid
  • Psychological first aid is an approach that is designed to minimize initial distress from an incident often immediately after an evacuation. It includes fostering a sense of hope and calm, but also emphasizes self-efficacy – helping the patient feel in control and a part of their own rescue. 


Communication when an event is unfolding can take various forms, but the key to planning for incidents in healthcare settings is to remember that the message is going to everyone in the building. As such, the coded language typically used in hospitals to communicate medical emergencies over a public announcement system is usually not sufficient. The DHS et al document recommends email and text messages in conjunction with lights and sounds to surmount language barriers. Healthcare settings should also consider, if possible, ways to communicate threats to local law enforcement simultaneously.

Adaptation – Modifying the “Run, Hide, Fight” Model

The FBI’s “Run, Hide, Fight” model, which we discussed on a previous Insights post here, is an effective template for most active shooter situations, but for healthcare, the potential volume of people that cannot or will not run makes it necessary to adapt the model.

  • For the “Run” piece of the FBI model, the DHS et al document notes that some people (patients and staff) will be in denial in the face of danger. Staff should be trained to identify what gunfire sounds like and to use directive phrases like, “Follow me!” or “Gun! Get out!” are good places to start.
  • For the “Hide” piece, best practices are finding “shelter in place” areas, (see above section) plus additional measures including: closing blinds if in a room with windows; turning off all lights; silencing electronic devices; hiding along walls away from the door; barricading doors with furniture; and identifying ad hoc
  • For the “Fight” piece, any ad hoc weapons identified in the “Hide” piece become useful. Fighting the shooter should always be a last resort, but incapacitation with available items in healthcare settings like fire extinguishers and liftable furniture should be discussed with staff. The DHS et al document also notes that there is strength in numbers – if several people confront the shooter with ad hoc weapons it is more likely they can stop him.

Healthcare employers have options for prevention and preparation. In addition to the recommendations above, we recommend learning about Commonwealth’s Active Threat Solutions product. Learn more about that here.