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Reports of active shooters occur almost weekly in the United States (US) and globally. In the past, most active shooter incidents occurred in businesses like post offices, factories, and corporations. Today’s general belief is that no profession, including healthcare establishments, is immune from gun violence due to active shooters. Active shooter incidents are as likely to occur in rural and urban healthcare facilities at any time. Unlike other businesses, the major problem with active shooter incidents in a healthcare facility is that unique challenges are posed in planning and response. Hospitals see thousands of patients every day, some of whom arrive due to gun violence. Gun violence is due to a myriad of factors, including the history or culture of a region and the local laws about the possession of firearms. Some events already have police on the scene (ie, in the emergency department), and the firearm is not necessarily brought into the facility. Moreover, hospitals have many entrances and exits, making planning for an active shooter incident complex. Further adding to the complexity of an active shooter is that most incidents occur without any hindsight and end quickly, often before law enforcement arrives. Thus, intervention by bystanders, hospital personnel, and other civilians may be necessary in a contingency plan during the initial phase of an active shooter at a healthcare facility.[1][2][3] Gun Violence Gun violence refers to the use of guns to inflict violence in settings, including healthcare facilities. Though gun violence has a multifactorial etiology, food insecurity is one common predicting factor, as well as underlying or undiagnosed psychiatric disease.[4][5][6] Hospitals located in food-scarce regions or food deserts may be more prone to active shooter incidents. Facilities that treat patients with psychiatric diseases may be at higher risk for such incidents. Possession of Firearms

Gun violence refers to the use of guns to inflict violence in settings, including healthcare facilities. Though gun violence has a multifactorial etiology, food insecurity is one common predicting factor, as well as underlying or undiagnosed psychiatric disease.[4][5][6] Hospitals located in food-scarce regions or food deserts may be more prone to active shooter incidents. Facilities that treat patients with psychiatric diseases may be at higher risk for such incidents. Possession of Firearms Within the US, state-to-state regulations vary regarding the possession of firearms. Healthcare professionals may agree or disagree depending on personal beliefs, and the focus on gun violence prevention is correlated to the increase in active shooter incidents, especially within hospitals and in the context of this activity. Several studies continue to examine the role of components of safe firearm use, including the use of safe storage, with insignificant results.[7][8] Background checks that examine psychiatric stability are not required as of yet. Emergency Management: What is a Contingency Plan? Because active shooter events are now a common occurrence in the US, all healthcare facilities must prepare contingency plans to limit damage and death. The contingency plan provides a framework for when and if the healthcare facility is subject to gun violence. This plan includes the floor plan of each hospital section, identifying exits, first aid kits, and places of shelter. Key personnel are identified to facilitate the execution of the plan. Law enforcement officials now actively assist the hospital administration in planning and guidance in dealing with active shooter events. In 2016, the Occupational Safety and Health Administration (OSHA) updated its healthcare safety field Rule 3148, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Incorporating an active shooter incident plan is a part of every healthcare facility’s emergency management plan.[9] Active Shooter Versus Shooting Incident: What is the Difference?

Because active shooter events are now a common occurrence in the US, all healthcare facilities must prepare contingency plans to limit damage and death. The contingency plan provides a framework for when and if the healthcare facility is subject to gun violence. This plan includes the floor plan of each hospital section, identifying exits, first aid kits, and places of shelter. Key personnel are identified to facilitate the execution of the plan. Law enforcement officials now actively assist the hospital administration in planning and guidance in dealing with active shooter events. In 2016, the Occupational Safety and Health Administration (OSHA) updated its healthcare safety field Rule 3148, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Incorporating an active shooter incident plan is a part of every healthcare facility’s emergency management plan.[9] Active Shooter Versus Shooting Incident: What is the Difference? Distinguishing between a shooting incident and an active shooter is important in emergency management protocols. An active shooter is a term used by law enforcement to describe a situation where a shooting is in progress, and this particular crime requires a set of protocols when responding to the incident. According to the United States Department of Homeland Security, an active shooter is “someone who is actively engaged in killing or attempting to kill people in a confined and populated area.”[10] The majority of active shooter events are preplanned. In most cases, the active shooter has already accepted the fact that they may also die. Active shooter events usually do not last long; most are over within 19 minutes, either because law enforcement stops the shooter, the weapon malfunctions/jams, or the person runs out of ammunition. However, within these 10 minutes, the shooter may cause damage. Data show that multiple people can be shot within a few minutes, and at least two-thirds of active shooter incidents are over by the time law enforcement arrives.

The majority of active shooter events are preplanned. In most cases, the active shooter has already accepted the fact that they may also die. Active shooter events usually do not last long; most are over within 19 minutes, either because law enforcement stops the shooter, the weapon malfunctions/jams, or the person runs out of ammunition. However, within these 10 minutes, the shooter may cause damage. Data show that multiple people can be shot within a few minutes, and at least two-thirds of active shooter incidents are over by the time law enforcement arrives. On the other hand, a shooting incident is a spontaneous, unplanned event that may involve 2 participants who either know or do not know each other. For example, a patient may have been unhappy with the surgeon following a surgical complication. The surgeon may unjustly blame the patient, and the latter shoots the surgeon. A clinician may also be upset at the manager for refusing to pay him overtime and draw a weapon. The unplanned or spontaneous events may occur because of impulsive action, extreme anger, or loss of control. Spontaneous shooting events in healthcare facilities usually involve 1 or 2 shots from a gun. They may be involved in a shooting between 2 or more individuals, for example, a spouse, manager, or colleague.

Responsibilities of Employers In the past, most workplaces in the United States had no plans to deal with active shooter incidents. However, the number of shooting incidents has caused most healthcare facilities to initiate measures to prevent or decrease the risk of active shooter incidents. OSHA has also made recommendations for employers in all government and healthcare facilities.[31][32][33][34] Some of the OSHA recommendations include the following: The workplace must offer employees a safe place free from physical hazards. The workplace should employ best practices and industry standards to ensure worker safety. The workplace must follow all state and federal guidelines regarding safety. Educate and create awareness among healthcare professionals about the possibility of an active shooter. Incorporate preventive measures from past shooting events Healthcare facilities that are not compliant with OSHA recommendations are liable for any injuries or deaths that occur during an active shooter incident. Several lawsuits have been filed against facilities with inadequate security or negligence.[18][35][36][37]