Almost on a weekly basis, there are reports of an active shooter in the workplace. There was a time when it was thought that an active shooter in a healthcare facility would never occur, but this notion is no longer held. From 2000 to 2011 there were 154 hospital-related shootings and since 2010 an additional 7 events.  It has happened most recently in the hospital of Wright air force base. In the past, most active shooter incidents took place in businesses like the postal service, factories, and corporations. The general belief today is that no profession is immune from an active shooter, including healthcare establishments. Active shooter incidents are just as likely to occur in both rural and urban healthcare facilities at any time. The one major problem with active shooter events in a healthcare institution is that unlike other businesses, there are unique challenges in planning and response. Hospitals actively see thousands of patients every day in many different departments. Some events have police already on scene (i.e. in the emergency department) so the firearm is not necessarily brought into the institution, it is the officers weapon. Moreover, hospitals have many entrances and exits, and this makes planning for an active shooter incident very complex. Further adding to the complexity of an active shooter is the fact that most events occur without any hindsight and end quickly; often before law enforcement even arrives. Thus, during the initial phase of an active shooter at a health care facility, intervention by bystanders, hospital personnel, and other civilians may be necessary if one is going to develop a preventive plan. , , 
Because active shooter events are now a common occurrence in the United States, all healthcare facilities must prepare to limit damage and death. Law enforcement officials now actively assist the hospital administration in planning and guidance in dealing with active shooter events. In 2016 OSHA updated their healthcare safety field Rule 3148, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Incorporating an active shooter incident plan must now be part of every healthcare facility’s agenda and emergency management plan. There is no one size intervention that fits all health care institutions and one must take into account, the size of the hospital, the different departments, geographical setting, patient access, available security and exits and location of staff offices. Each work area has distinct features that require attention. 
It is important to make the distinction between a shooting incident and an active shooter. 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 protocol when responding to the incident. According to the US 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.” (DHS, 2013) 
The majority of active shooter events are preplanned; the shooter usually has prepared himself well with the aim of killing as many individuals as possible. In most cases, the active shooter has already accepted the fact that he or she may also die during this shootout. The active shooter events usually do not last long; most are over within 19 minutes, either because law enforcement stops the shooter, the guns jam, or the person runs out of bullets. However, within these 10 minutes, the shooter can do a lot of 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 two 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. Or a healthcare worker may be upset at the manager for refusing to pay him overtime and may pull out a gun. The unplanned or spontaneous events may occur because of impulsive action, extreme anger or loss of control. The spontaneous shooting events in healthcare facilities usually involve one or two shots from a gun and may be involved in a shooting between two or more individuals, for example, a spouse, manager, or colleague.
Why do Active Shooter Incidents Occur?
While some active shooter incidents are spontaneous and driven by emotions, most are preplanned. In those situations which are pre-planned, the active shooter may have had a grudge, may have been terminated or treated harshly, and in return, the individual plans of taking revenge. Unfortunately, when a shooting incident occurs in a health care facility, it is impossible to know whether it is a spontaneous event or something that has been preplanned. Most people attempt to hide rather than confront the shooter to determine the reason. , , , , ,
Understanding the Problem
When an active shooter incident is taking place in a health care facility, it is important to know what type of violence is taking place. Is it a spontaneous event involving two people who know each other, (shooting incidence) or is this a preplanned shooting incident designed to kill many people (active shooter). To understand the hazard, one has to be aware of the different types of workplace violence. The key reason to understand the different types of shooting incidents is that it allows for a better understanding of the crime and one can then take steps to prevent or deter the event. One of the key features of any type of preventive action is that the more people know about the different types of shooting incidents that can occur, the more likely is that preventive measures can be undertaken. More people involved means that there are more "ears and eyes" that can sense abnormal behavior. Today, law enforcement has classified active shooting incidents into five categories:
What is Hybrid-Targeted Violence (HTV)?
HTV is defined as the use of violence which targets a specific population or a group of individuals using a variety of unconventional and conventional weapons combined with tactics to ensure large kills. Individuals involved in HTV often target several locations at the same time. Some examples of HTV over the recent years include incidences at the following places:
HTV incidents are not novel and have been occurring time and time again, not only in the United States but in many parts of the world. In the majority of HTV events, the individuals involved are part of a terrorist group or those with fanatical religious/political ideologies. Tragically over the past 2 decades, many international terrorist groups have tried to conduct HTV attacks on American soil because of American foreign policy. One large recent attack in Afghanistan indicates that HTV has the potential to occur on US soil, in healthcare facilities.
Characteristics of HTV
Unlike the active shooter incidents usually conducted by one or two individuals, in an HTV attack, there may be many individuals who are well trained, know how to operate a variety of weapons, and are willing to die. Most of the HTV attacks may involve small groups of attackers in different locations. Furthermore, these individuals also manage to communicate with others in the group. The key feature of an HTV attack is that it usually involves attracting the first responders so that more damage can be inflicted. F or example in Israel, Palestinians have been known to knife people on the streets, and when people gather, the same perpetrators call for an ambulance which carries more attackers so that they kill first responders. In some cases in Iraq and Afghanistan, the attackers have even complicated the event by inducing fires, thus causing more harm. The big worry is that one of these days an HTV attack may involve the use of CBRN agents. In Syria and Afghanistan, HTV attackers have been known to possess high-grade exposure, high powered military weapons, and even suicide bomb vests.
Hospitals and Terrorist Attacks
Over the past few decades, there are have been at least 10 dozen terrorist attacks on healthcare facilities in 43 countries. These attacks have resulted in 1217 injuries and 775 deaths. Terrorists now identify hospitals as viable targets. They are fully aware that by disrupting care, the terrorists can cause significant deaths. In addition, by attacking a health care facility, the terrorist can also distract law enforcement and emergency medical services from going to the primary target area. Thus individuals wounded at the primary site cannot be helped. 
Shooting Incidents in Hospitals in the United States
Since 2000, there have been 154 hospital-related shootings involving 148 hospitals. The events resulted in 235 injuries, some of which include deaths. In the last decade, the incidence of the hospital-related shooting appears to be increasing annually. Hospital shootings have been known to occur in hospitals of all sizes. Over the past 2 decades, at least 51% of shootings have occurred in hospitals with less than 40 beds. However, as the number of hospital beds in a hospital increases, the number of shootings drop, perhaps indicating that small hospitals are easier to maneuver and have less stringent security. , 
About 60% of shootings have occurred inside the hospital and 40% outside the hospital. The most common locations for the shootings include the following:
Who is the Shooter?
In more than 90% of cases, the shooter is a male. While many shooters have been young males, in some cases, shooters have been seniors.
What is the Motive for the Shooting?
Who are the Victims?
In the majority of hospital incidents, there is one active shooter and one victim. Only in about 10% of incidents were there more than three victims. Tragically when they are multiple victims, at least 60% to 80% have been innocent bystanders. The rest include physicians (3%), patients (13%), and nursing staff (5%).
After the shooting, nearly 50% of the shooters committed suicide. Less than 10% of the time is the active shooter captured alive.
Relationship Between the Shooter and Victims
In many incidents, the shooter already knows the target, or he had some relationship. Over the years the following relationships have been identified between the shooter and the victims:
Unlike non-hospital shooting events where close to 25% of victims have no prior relationship to the shooter, in hospital settings, more than 50% of the time, the shooter and the victim have known each other. Hospital shootings are not random and are often personal and targeted. Many hospital shootings are due to a personal grudge against the ex-spouse, doctor, nurse, or a colleague.
What are Behavioral Indicators of Potential Shooters?
What Weapons are Used by the Active Shooter?
In most cases, the active shooter will use a firearm. In rare cases, the active shooter may use other weapons and/or even improved explosive devices that cause more injuries and act as an impediment to law enforcement and emergency responders. Some of these improvised explosive devices may detonate immediately or may have delayed fuses. Thus, no attempt should be made to go near or handle these devices.
The Hospital Environment and the Shooting Incident
Most health care facilities have a large number of visitors, patients, and important medical staff on hand, and thus any shooting incident can result in mass casualties. Thus, to someone determined to cause mayhem and chaos, the hospitals are soft targets. Most hospitals are rich in targets, and if there is an active shooter in a critical sector, it can lead to a cascade of events with a high number of deaths. For example, a shooting in the emergency room can paralyze the hospital as it is the core area where patients are resuscitated. Without a viable emergency room, injured individuals have nowhere else to go for help.
Challenges in Hospitals with an Active Shooter
Presence of an active shooter is a hospital can be challenging in many ways, and they include the following:
Special Areas of Consideration
When an active shooter is present in the hospital, many critical places need to be considered.
Before any type of preventive measure can be undertaken it is important to evaluate the workplace. For example, the emergency room is very different in its settings to the intensive care unit in terms of potential for violence and death. In fact, in all hospitals, some areas are easily accessible and others are not. For example, one can access the emergency room but it is not possible to enter a mental health department which usually has locked doors and requires a password to enter or exit. To ensure that the healthcare facility is adequately prepared to deal with an active shooter incident each area of the hospital must undergo its own assessment, planning, and exercise.
While one can conduct multi-department assessment and exercise, this is also fraught with errors. For example, one needs to know who is or are the shooters and who are the intended victims. Exercise in the emergency room must always take into account the number of patients and visitors who may be present; whereas, in the mental health unit, it is usually one perpetrator, and the intended victim may be a staff member. Furthermore, in the emergency room, one has to consider many exits and entrances; whereas in a place like the ICU there is usually one entrance and exit. In the emergency room, it is hard to create a safe room because the area is usually wide open and often has several entrances. , 
Active Shooter Response Options
There are different active shooter response options that have been developed over the years with the predominance of the response types coalescing into several simple principals: Run, Hide, Fight. ALICE Training Institute, Department of Homeland Security, Ready.gov, FEMA are several entities that have created active shooter response training.
When law enforcement officers arrive, do exactly as they instruct since they have no idea who the shooter is. Avoid making quick movements and do not place your hands in your pockets. Further, avoid screaming or yelling. Follow the instructions on evacuation and go to the designated area.
Planning to counter an active shooter involves an interprofessional team with a multidimensional approach. There is no one approach that works all the time and the threat must be continually assessed.
Facility Initiatives to Thwart Active Shooter Incidents
Should Employees be Trained to Counter Active Shooters?
The reality is that most active shooting cases occur suddenly and are over in a matter of minutes. Most employees usually are too afraid and often consider hiding in a safe place. For employees who have a chance to hide this should be the first goal in mind rather than confronting the gunman. Confrontation is only necessary where there is no other option left. Both law enforcement and hospital policies recommend not confronting the gunman.
What Type of Training is Useful when Confronting an Active Shooter?
While law enforcement arrives, some of the tactics used to distract the gunman include the following:
Use of Bystander Intervention
One way to stop an active shooter is with assistance from bystanders. In almost every case of the active shooter, law enforcement takes a few minutes to arrive at the scene. So should bystanders play a role in overpowering the shooter? Most experts in law enforcement indicate that the use of bystanders to counter the active shooter is not recommended and is usually the last choice. However, if the bystander has a weapon and knows how to use it, then he or she may confront the shooter. But for most people, countering the active shooter is not recommended.
Instead of fighting the active shooter, experts say that bystanders should try and help any injured victims. While some have suggested that bystanders try and stop any source of bleeding, this is not something a non-health care worker can do. Even most trained health care workers who have not been trained in emergency medicine or surgery would have no idea how to stop bleeding. Plus, one also needs the right equipment, lighting, and assistance to stop the hemorrhage. Blindly placing clamps inside the body to stop bleeding is more likely to cause more complications and can even result in a lawsuit. Thus, unless there is a surgeon or emergency room physician present, no attempt should be made to stop internal bleeding. Superficial bleeding can in many cases be stopped with digital pressure or a bandage. Instead of focussing on bleeding, one should try and ensure that the injured victim has a patent airway. Since most shooting events are over in a matter of minutes, the next step is to call 911 or the operator to get medical help.
Emergency Escape Routes
Employees or former employees who become active shooters are fully aware of exits and entrances in the healthcare facility where they work. So when it comes to developing escape routes, the following is recommended:
There will always be some patients who cannot move, so they will have to be left behind, but someone should stay around if the patient is on the ventilator or acutely ill. Patients in the NICU, ICU, dialysis unit, or the surgery recovery room usually cannot be moved, and moral dilemmas may occur as to whom to take and whom to leave behind. Even those left behind need care. For example, one simply cannot leave an infant on a ventilator and escape. The hospital should have a policy for what to do in such circumstances because there is always the threat of litigation if someone sick is left behind.
First Aid Kits
When an active shooting incident occurs, some people are usually killed outright, and there is no chance of saving them. But then there are others who may be injured by the shooter or may have been hurt during the attempt to flee. Some may jump from a building, others may break down windows to escape, or yet others may crawl through hazardous terrain. When people are injured, there must be preplanned first aid kits around the hospital to provide oxygen, help stop any bleeding, warming blanket, or splint a fractured extremity. These first aid kits must be placed in all departments because one may never know when they may be required. Further, these kits must be rechecked to make sure that the supplies are not expired or not functioning. Hospital staff must know where these emergency kits are located and must have some basic training to manage emergencies. If there is a device or equipment, it must come with instructions so that even a bystander can put it to use.
What should the readily deployable first aid kits contain?
Many types of first aid kits are available for use, but one has to remember that during an active shooter incident, there is no time for formal medical or surgical procedures. The kit should only contain the essentials so that the injured victim can be made more comfortable. Since the majority of people involved in active shooting incidents are non-healthcare professionals, the kit should contain the following:
When an active shooting incident is taking place time is of the essence as most events are over in minutes. In many cases, valuable time is lost because of the panic and confusion which leaves people exposed and vulnerable. Thus, it is vital that all communications regarding an active shooter be clear, concise and actionable to prevent worsening of the situation. The best way to foil an active shooter is by eliminating the targets.
Lucid Language Messaging
Law enforcement suggests that the communication to the masses about an active shooter should be in simple language. Code words should not be used because many people may not know what they mean. During an active shooting event, people are often hysterical and panicky and may not even remember what the code words mean. The communication should provide accurate information about the shooter, location and give out clear instructions on where and how to proceed.
Immediate Psychological Support
An active shooting incident can be extremely traumatizing, and thus experts in mental health suggest that one should try and manage the immediate psychological trauma. In many cases, some people can become irrational or very emotional which interferes with the evacuation and can place others at risk. Psychological first aid should be offered right away, and the responders should try and limit the negative or distressing news that can instill more fear and panic. Psychological first aid is ideal for any individual experiencing an overwhelming emotional response to a violent event. The individual may or may not have a prior mental health condition. One does not have to be a healthcare provider to offer psychological first aid but use common sense and be realistic. The aim is not to cure any type of emotional disorder but to limit the panic so that evacuation can proceed safely. All you have to do is calm the individual down.
Responsibilities of Employers
In the past, the majority of workplaces in the United States had no plans for dealing with active shooter incidents. However, the number of shooting incidents has promoted most healthcare facilities to initiate measures to prevent or decrease the risk of active shooter incidents. Plus, in all government and healthcare facilities, OSHA also has made recommendations for employers. , , ,  Some of the OSHA recommendations include the following:
Finally, it is important to be aware that health care facilities that are not compliant with OSHA recommendations can be held legally liable for any injuries or deaths that occur during an active shooter incident. Several lawsuits have already been filed in court that have accused the facilities of inadequate security or negligence. , , , 
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