A Growing Threat to Healthcare and Other Facilities

Shooting incidents and other attacks seem to be increasing. In many cases, domestic violence has become a common denominator and one that has many opportunities for prevention. While the domestic violence threat alone is tragic, these incidents can become more deadly when they transcend the home and enter the workplace, resulting in secondary victims being harmed. Perpetrators who are unable to vent their frustrations on the intended target may transfer their aggression toward others who simply get in the way.

Active Shooter & Violent Incidents

Numerous facilities such as nursing homes, assisted living facilities, and small outpatient clinics have become targets of violence. Here are just two of the numerous examples that span the country. On May 12, 2017, the small community of Kirkersville, Ohio (population ~500 at the time) was rocked by a violent encounter. Much like other small communities around the nation, Kirkersville never expected a criminal act of this nature. A routine day ended with an event gone tragically wrong as a nurse who worked at the local nursing facility became a domestic violence target. Several other individuals present simply got in his way. The new police chief, who had been on the job for three weeks, responded and was killed in an ambush by the assailant. The assailant then forced his way into the facility where he confronted and killed a nurse’s aide. The assailant then moved through the facility in search of his ex-girlfriend. The assailant found and killed her, then took his own life. A search of his home after the incident revealed more than 60 firearms he had purchased or come into possession of despite his extensive criminal history and record. While protection from domestic violence is paramount, another threat has emerged. Much like domestic violence, the insider threat provides another unique challenge for planners. On February 4, 2021, the city of Lafayette, Colorado (population ~34,200 at the time) saw such an incident take place at a nursing home facility. Reports indicate that a resident of the facility had shot and killed the maintenance man, whom the shooter accused of stealing his money. His attack was methodical in nature as the resident watched his victim complete his safety checks and then shot and killed him. The killer was a 95-year-old resident of the facility who made numerous threats in the past as well as statements to the effect that he was going to kill people. Most interestingly, he had a firearm in a facility that did not allow them, and the facility staff had previously disarmed him on another occasion. Small facilities like these have increasingly become targets of malicious acts of violence. However, violence is not limited to assisted living facilities or nursing homes. Other medical entities are also targets of various types of violence, including small outpatient clinics. IStock/ @ OZANKUTSAL

An Expanding Threat With Significant Consequences

With medical facilities continually having to deal with increased patient loads and shortages of medical personnel, the chance for violence against doctors, nurses, and other support personnel can and has increased exponentially, with healthcare workers accounting for about half of workplace violence victims. Statistics that are tracked each year show that the type of violence most prevalent in these facilities is Type 2 Workplace Violence. The National Institute for Occupational Safety and Health (NIOSH) identifies this as violence from a customer or client, including patients, their family members, and visitors directed toward healthcare personnel. With the emergence of COVID-19, which led to many being confined to their homes, there has been an increase in violence across the spectrum. As dangerous as this occurrence is, there is a potential for this type of violence to occur in other medical venues separated from the primary facility. This threat involves those that may serve smaller communities or provide outlier medical services on a 24/7 basis. For example, on February 9, 2021, five people were shot (one later died) inside the Allina Health Clinic in Buffalo, Minnesota (population ~16,700 at the time). The clinic was a small outside facility that provided outpatient care. With numerous events of active shooters occurring across the country in numerous venues, increasing threats against outpatient and other associated facilities can be overlooked. Much like the increase in attacks against houses of worship, places of healing should become more aware of such direct and indirect threats, regardless the size of the community. Outpatient clinics and those that may provide services in a 24/7 emergency capacity could become a new category of facility to experience violence. In many cases, these facilities are minimally staffed and may not have security staff present to deter crime and secure the facility. Some facilities have never had a security assessment or other review of the structure, which may deter or prevent crime. Some buildings may have been used previously for other functions or may be located in relatively high-crime areas. Consequently, these facilities provide a dangerous combination of conditions where an attack of a personal or non-personal nature may take place.

Guidance for Preparedness & Response

There is no one-size-fits-all application and no perfect program that can prevent every action from taking place. However, some processes and programs can be applied to mitigate the threat. For example, information garnered from previous incidents can be used as a guide for preventing them from occurring in other organizations. Although no two organizations are the same in form or function, there are enough similarities to benefit from examining others’ failures and applying lessons learned. The Department of Homeland Security developed such a program many years ago to look at individual incidents and programs to provide a lessons learned database for organizations to research. The same should be developed for medical organizations or those providing assisted living services. The Lessons Learned Information Sharing (LLIS) can still be accessed through the Naval Postgraduate School CHDS program. Next, the employment of Crime Prevention Through Environmental Design (CPTED) could be added as a method to assist in designing the environment that would make the facility and surrounding area less of a target for a criminal element. This could also make it more inviting for the local population to use. CPTED, although an older concept, is one of the best methods available to “design out” crime. The process has become so engrained in applications for safety and security that it has taken on new applications in the prevention of terrorist attacks. The programs associated with this concept work and have had a positive impact across the spectrum.

The threat is real, and the consequences can be high with a major loss of life. Regardless the size of the city or facility, shootings and other attacks can happen.

In concert with CPTED should be the application of a risk assessment to address current physical security aspects of the facility as well as the current procedures and policies that are applied thereof to perform emergency and day-to-day functions. The CPTED concept and risk assessments complement each other in their application. The risk assessment examines external and internal issues that may promote or prevent violence in the facility. Assessments of this nature should be completed by a certified CPTED and/or risk assessment specialist. A list of CPTED certified specialists can be found at the National Institute of Crime Prevention (NICP). Training is another aspect that should be developed to prepare personnel in the facility. For many years, training on active assailants has been conducted under the guise of the active shooter. However, many points are still missed that apply to an active shooter event. These need to be addressed. Active shooter training is important and should be continued, but areas contained in an Active Shooter Hostile Event (ASHE) program should be expanded beyond just that scenario. Areas that should be covered and made available to everyone in the immediate area include Stop the Bleed®, CPR and AED programs, and the development of Stop the Bleed kits. The National Fire Prevention Association (NFPA) provides guidance to assist in the development of programs within medical and assisted living organizations. Making situational awareness instruction a requirement for all personnel would not only assist individuals while operating in the medical facility, but it also would apply to their daily lives outside the facility. This type of training is a value-added process that builds awareness of potential dangers inside the facility, outside in the parking lot, or in public areas like malls. Finally, facilities should establish a See Something, Say Something program, which makes everyone responsible for the safety and security of personnel inside and outside the facility. The program has been successful at many levels and can be applied in daily operations. These suggestions do not cover the entire set of programs that may be needed at any specific facility because each facility is unique. However, the danger is real, and more effort is needed to ensure that threats inside and outside an organization are identified and planned for when possible. The development of a threat matrix and a multiyear training plan can help organizations meet their training needs. Each effort an organization makes is one more step in preparing individuals to be safe. As a guide, organizations should look to the International Association for Healthcare Safety and Security (IAHSS) for suggestions.

Real Threats With Significant Consequences

The threat of active shooters and other violent incidents is real, and the consequences can be high with a major loss of life. It does not matter how large or small a city is, how large or small a facility is, or what the major function of a facility is at present. Shootings and other attacks can happen. While each type of incident mentioned above can be viewed as isolated in nature, these examples indicate the myriad of threats that hospitals, medical centers, smaller outpatient clinics, nursing homes, and assisted living facilities can face. Organizations must look at threats beyond that of active shooters. When entities focus on one specific area, the threats that exist from other entities become blurred. It may become clear when an incident occurs, but by then it is too late. Planning must be a whole community process and include everyone concerned. By doing this, everyone becomes part of the planning and will be able to better identify and prevent incidents from happening.