Who is the active shooter in a healthcare setting? No real profile exists, but research in other settings indicates there may be signs or indicators, according to a recent report by the Department of Health and Human Services (HHS).1

For example, a report on campus shooting incidents by the Federal Bureau of Investigation and other agencies made several key observations related to pre-attack behaviors. Concerning behaviors were observed by friends, family, associates, professors, or law enforcement, the HHS reports. These behaviors included paranoid ideas, delusional statements, changes in personality or performance, disciplinary problems on site, depressed mood, suicidal ideation, non-specific threats of violence, increased isolation, “odd” or “bizarre” behavior, and interest in or acquisition of weapons, the HHS notes. Other behaviors often include development of a “personal grievance,” a major life event involving “real or perceived personal loss,” such as a death, breakup, divorce or loss of a job.

Given these various and sundry manifestations, it may come down to trusting a gut feeling about a particular person or situation.

“Pilots and other people in high-stakes fields learn how not to ignore their gut feelings,” says Michael Dorn, executive director of Macon, GA-based Safe Havens International, which provides training to prevent violence on campuses. “If you have a patient who is not acting like patients typically do in a situation, then key in on that. What we know is people can key on specific indicators of danger because the brain is picking up patterns of behavior that are not the norm.”

For instance, a patient or family member might exhibit inappropriate anger when meeting with hospital providers or behave in a way that causes a nurse to feel something is off. It’s these gut feelings that nurses and other staff should pay close attention to, Dorn says.

Three moments in time

The HHS document is aligned with the three time frames associated with an active shooter incident: pre-incident, incident, and post-incident response, observes Dan Hartley, EdD, workplace violence prevention coordinator at the National Institute for Occupational Safety and Health (NIOSH). While still a relatively rare event, hospital-based shootings nearly doubled in one study — going from nine active shooter incidents per year during 2000-2005 to almost 17 per year during 2006-2011, he notes in a NIOSH blog about the issue.2 In the study, the emergency department was the most common incident site (29%), followed by the parking lot (23%) and patient rooms (19%). Most events involved a determined shooter with a strong motive as defined by grudge (27%), suicide (21%), “euthanizing” an ill relative (14%), and prisoner escape (11%).3

“The active shooter incident is still an anomaly in the healthcare setting,” Hartley observes. “However, training in how to prevent and respond to an active shooter incident is very important and should complement training in prevention and response to other more prevalent types of workplace violence.”

The HHS report says healthcare employees should learn the signs of a potentially volatile situation that could develop into an active shooter incident. Each employee should be empowered to proactively seek ways to prevent an incident with internal resources or additional external assistance, the report states.

“During an active shooter incident, the natural human reaction, even for those who are highly trained, is to be startled, feel fear and anxiety, and even experience initial disbelief and denial,” the HHS says. “There may be noise from alarms, gunfire and explosions, and people shouting and screaming. Training provides the means to regain composure, recall at least some of what has been learned, and commit to action.”

The HHS recommends health care workers be taught the easy-to-remember mantra: “Run, Hide, Fight.” As healthcare facilities train and discuss these options, they should be viewed on a continuum. Everyone should be trained first to run away from the shooter, if possible, encouraging others to follow. If that is not possible, they should seek a secure place to hide and deny the shooter access.

“As a last resort, each person must consider whether he or she can and will fight to survive, incapacitate the shooter, and protect others from harm,” the HHS notes. “Though this may seem extreme, in a study of 51 active shooter incidents that ended before law enforcement arrived, the potential victims stopped the attacker themselves in 17 instances. In 14 of those cases, they physically subdued the attacker.”

That said, healthcare workers may have challenges unique to their field and feel conflicted about, for example, abandoning patients by running away. “Healthcare professionals may be faced with the decision about the safety of patients and visitors in their care who may not be able to evacuate due to age, injury, illness, disability or because of an ongoing medical procedure,” the HHS report notes.

This “sensitive topic” could be discussed in an open conversation with employees. The HHS guide provides some points for discussion, saying that addressing the topic may be uncomfortable to some and reassuring to others in the sense that the facility is trying to address a very difficult scenario. “There is no single answer for what to do, but a survival mindset and open and honest discussion can help increase the odds of survival.”

Spotting weapons, unusual patterns

According to Dorn, some other specific ways hospital employees can be trained in a violence and active shooter prevention program include visual weapon spotting and pattern recognition.

“People can be trained to identify specific cues that someone is carrying a weapon,” Dorn says. “For example, a jacket sag: If you stick a gun in the pocket of a jacket, then the jacket will pull tight on that side of the body and the gun may bounce against your hip as you walk.”

Hospital security and emergency room or reception staff can be trained to spot the outline of a gun in someone’s pocket.

“The key is to train people to observe these cues and then to empower them so nurses and other healthcare workers feel free to act on what they observe,” he says. “You need to have systems in place so they can see things, size up the situation, and act fast enough by pushing a distress button or calling someone to start a chain of events to prevent violence.”

Pattern recognition may include a routine event playing out in an unusual way. Dorn offers the example of a police officer at a middle school who watched from a football field away a school bus in which the pattern of kids quickly climbing on board was different. Instead, the children were milling around the bus and not getting on. The officer went to the scene and saw that three men across the street ere waiting for the kids to get on the bus, apparently targeting a particular student. He approached the men, who ultimately were arrested.

An unexpected benefit to this type of training is that the attention to detail often translates to better customer service, Dorn notes. “When a hospital trains staff on pattern visual recognition, it creates better connectivity to people, and it makes reception staff more attentive to someone coming into the lobby,” he adds.

Workplace violence often is related to domestic violence, so hospitals should screen employees and provide background checks. Employee health directors also should encourage hospital managers to adopt a discrete, open door policy when it comes to employees discussing personal life issues that might impact their working lives, Dorn suggests.

“Emphasize that people have situations that come up and can cause risk, so if an employee is having problems with a girlfriend or boyfriend, a neighbor, spouse, ex-wife or ex-husband, then the worker needs to talk about it with a manager,” he says.

Reporting personal conflicts can save lives, he adds. “We had a situation where a teacher met a guy at a bar, gave him her personal information and then regretted doing so because she became afraid of the guy,” Dorn recalls. “The man was a stalker, and the employee came to her administrator and discussed what was going on.”

The administrator advised workers to be on the look-out for the man and his vehicle type. One day a custodian saw the car in the parking lot. Police arrived and found that the man had a gun and may have been intent on shooting the teacher.

“It’s not easy for employees to talk about personal problems,” Dorn says. “So you need to create an environment of trust where they feel comfortable doing that.”


  1. Department of Health and Human Services. Incorporating Active Shooter Incident Planning Into Health Care Facility Emergency Operations Plans. November 2014: http://1.usa.gov/1bzTRV0
  2. Hartley, D. Violence in Healthcare. NIOSH Science Blog March 27th, 2015 http://1.usa.gov/1BDBfZW
  3. Kelen, GD, Catlett, CL, Kubit, J, et al. Hospital-Based Shootings in the United States: 2000-2011. Ann Emerg Med 2012;60(6):790-798.