Violence in hospitals has grabbed national headlines in recent months. In July, a patient ranted about a gun ban at a Pennsylvania hospital and then opened fire, killing his caseworker and wounding his psychiatrist before the doctor pulled out his own weapon and fired back, wounding the patient. The shooter had 39 unspent bullets on him when he was wrestled to the ground, according to reports.
In May, a man returned to a Utah hospital's emergency room and pulled two handguns after being turned away for care there earlier. Two probation officers who happened to be with a parolee at the hospital shot and wounded him. No one else was injured.
According to security consultants, a case involving a doctor with a weapon is highly unusual. But hospital staffers, especially those working in ERs or mental-health units, must be ready to react; they have been cited by OSHA as being among the types of workers at higher risk for workplace violence.
Shootings at U.S. hospitals may occur several times annually—and typically involve mercy killings, disgruntled family members shooting doctors over perceived care shortcomings, or prisoners disarming police escorts in the ER; but there are many smaller incidents and threats: some reported and some not.
John White, president and CEO of of Protection Management LLC in Canton, Ohio, recalled speaking to a hospital's ER doctor who wanted to have metal detectors put in place, but quipped not to have him go through the screening "or you won't like the results." When hospital administrators learned of this encounter, "they laughed it off," he told Healthcare Dive.
"I don't think any hospital out there would make the decision to allow staff to carry firearms," White said. Yet hospitals "need to take a serious look at what their risks are [with respect to firearms coming into the workplace]. There's a likelihood it's going to happen."
How prepared are hospitals?
White and other security experts warn that hospitals must be proactive in assessing potential risks and preparing for them, and hope that the latest incidents help heighten awareness of potential threats. In addition to an array of industry guidelines and standards focusing on hospital workplace safety, some states are taking action. A relatively new California law, for example, requires hospitals to conduct annual risk assessments and to report violent incidents to local law enforcement
The American Hospital Association asserts that hospitals in general are doing what they must do.
"Hospitals take security and the safety of their patients and employees very seriously," AHA spokesperson Jennifer Schleman said in a statement to Healthcare Dive. "As part of their 24/7 standby role, every hospital has an emergency plan that they regularly exercise and update. America's hospitals must prepare for all kinds of emergencies, including security incidents that occur within the hospital. Many hospitals plan for and exercise scenarios involving active shooters."
Security consultants respond that, whether they do the work or it is done in-house, hospitals must tailor programs and policies to their specific needs. Some have detailed, sophisticated security plans at the ready, experts say, but many others, facing cost pressures, are not as inclined to invest much in security since it is not a revenue-producing initiative and it is tough to prove a financial return.
"Security is often a casualty," as one consultant put it. But this consultant, an expert witness in hundreds of lawsuits involving hospital security over the past few decades, said this approach is short-sighted: "One of these litigations would pay for a lot of security. They run into the millions [of dollars]."
According to White, hospitals' level of preparedness varies markedly. The security consultant said he has asked hospitals "What's the biggest threat to your organization?"—and they couldn't answer. Yet, says White, they were in a high crime area.
White said he has visited several hospitals with no security staff or management, just someone told to cover threats if they should arise. "Smaller hospitals, especially under 100 beds, don't have the resources for security staff," he conceded, "but they need someone knowledgeable who's responsible for security and need processes in place."
A recent survey found that violence in hospitals is a growing public health concern. The violent crime rate per 100 beds climbed from 2012 to 2013: disorderly conduct, theft and motor vehicle theft decreased, but vandalism and burglary slightly increased.
Gone are the days when hospitals were considered sanctuaries, Marilyn Hollier, president of the International Association for Healthcare Security & Safety (IAHSS), said when the survey was released in June. She said part of the increase is likely attributable to better reporting: nurses "not accepting that patient slap, pinch or punch as "part of the job.'"
Security shouldn't be incident-driven
But clearly there is more going on, and perhaps not much enthusiasm among hospital administrators for dealing with it. "I think we need to get [hospitals'] senior leadership engaged with this stuff. A lot of senior leaders think, 'We've got the police department on the corner'" to rely on if problems arise, said Tom Smith, president of Healthcare Security Consultants, Inc. in Chapel Hill, N.C.
Security tends to be pushed aside unless there is an incident, Smith said. "Our mantra is that security is incident-driven, and it shouldn't be," he said.
Smith cites several steps that hospitals should be taking now. First is a comprehensive evaluation of the hospital security program and its workplace violence policies, making sure that senior leadership is supportive. Hospitals also should set up and train threat management teams that include representatives from the legal, security, human resources and psychiatry departments, as well as local law enforcement.
Smith also suggests that hospitals put flagging systems in electronic medical records. In this way, he said, staffers are made aware of threatening patients and family members and of patients with violent criminal records. Also, he said, hospitals should train staff on crisis intervention, and must be sure to design security into new construction and renovation projects, using IAHSS guidelines.
It could be as simple as designing higher counters or certain types of doors for a hospital, Smith said.
Smith said he became involved in projects where, post-construction, hospitals were preparing to hand new keys to staff and realized that a floor couldn't lock a back entrance. Or they realized that a stairwell wasn't built into a corridor contiguous with the elevator (There must be two ways off a floor for safety purposes, so doors couldn't be locked because people in the lobby needed access to stairs in the clinic).
"I think good security is good customer service," Smith said. He recalls being told by a hospital administrator that putting a metal screener at the ER entrance would make people think it was a high crime area. "I say people will feel better and it will improve patient and employee satisfaction scores."
Smith said hospitals' push toward family-centered care without visiting-hour restrictions is fine, but only to a point. "You absolutely have to screen visitors. You have to know who's in your facility, especially after normal business hours." Hospitals also must monitor access to patient floors, he said, or it will open them to security vulnerabilities.
'I know what can happen when you don't do it right'
Bill Nesbitt, president of Security Management Services International, said he has been an expert witness in more than 650 litigations over security in the past 30 years, some having to do with hospitals, "and I know what can happen when you don't do it right."
A crucial part of security management involves an understanding of human behavior, Nesbitt said. Most of the time with active shooters at hospitals, he said, "the person who does it has some sort of a beef with the hospital and/or it's a mercy killing...When something goes wrong, it's my belief that a high percentage of the time, the nurse or person on duty missed the tell-tale signs."
He recalls being in an ER at a small hospital in northern California when he saw a man sitting in the waiting room rocking back and forth in his chair. Nobody noticed or acted, so he suggested to the charge nurse that it was a sign of anxiety that might result in a violent outburst. She asked this man, the anxious father of a child in the ER, whether he wanted a glass of juice; he did and calmed down.
In similar situations, Nesbitt said, "I've seen people pick up the chair and throw it through the window...People should be trained to perceive it. If you see aggression in stage one, you have an 80% to 90% chance of calming them down before the fact. But sometimes ER staff have tunnel vision..."
In the end, it may not take much to make a difference in preparing against potential hospital threats.
Nesbitt once asked staff at a major hospital whether they were told to look out for suspicious people. "They said, 'Yes,' but nobody could articulate what a suspicious person was," he said. "It took maybe 20 minutes for me to teach them what it meant...and in about an hour we got everybody up to speed."