Executive Summary

Shootings and other violence in healthcare facilities are increasing, which is prompting administrators to take another look at their security. Experts caution that priorities sometimes are misplaced and that failing to protect employees can lead to significant liability.

• A violent incident at a Virginia hospital proved the value of extensive preparations for such an emergency.
• The number of shootings at hospitals has increased significantly.
• Violence Often Is Associated With Long Wait Times, Psychiatric Patients, And Patients Under The Influence Of Drugs Or Alcohol.

Hospital plans tested in lockdown with bank robber on the loose

It is never good news when your phone rings at 3 a.m. and the caller ID shows your hospital’s emergency operations center. Whatever is happening at work is bad, and you’re about to find out if you prepared adequately for it.

The risk manager and other hospital executives at Inova Fairfax Hospital in Falls Church, VA, received that call recently and were told there had been a shooting, with a bank robber loose in the hospital.

A convicted bank robber being treated at the hospital stole a guard’s gun, with a shot fired in the process, and held her hostage before fleeing. The incident prompted a five-hour lockdown of the facility. The hospital’s preparations for such an event helped minimize the impact, says Greg Brison, the hospital’s director of emergency management and security.

A key part of that preparation was the workplace violence training required for employees at least once annually. That training includes information specific to responding to shots fired in the healthcare system. Inova Fairfax also works closely with local law enforcement and other emergency responders. In fact, it allowed them to use a new patient care facility for training before the hospital moved in any patients, and they used a scenario very similar to what actually happened. (For more on the incident at Inova Fairfax, see the story in this issue.)

The hospital had conducted full-scale drills as well as tabletop exercises to test its planning for an active shooter, including a meeting held just the day before the shooting. The Inova Fairfax incident illustrates how quickly a violent incident can put thousands of people in jeopardy and disrupt hospital operations, Brison notes.

No one was injured at the hospital during the incident, and patient care resumed as smoothly as could be expected after a long lockdown. (For more on the lessons highlighted by the Inova Fairfax incident, see the story in this issue.)

“There’s no question that our planning and the extensive training for our employees made a difference in the outcome,” Brison says. “This is the kind of thing you hope never happens, but if it does, you want your people to know what to do and how to stay safe.”

Increasing violence

Healthcare workers are increasingly at risk from violence at work, and their employers face the prospect of huge payouts if they are found negligent for failing to protect employees and patients.Violence in healthcare is not what it used to be, the experts say, and the typical precautions might no longer be enough.

Some level of violence has always been an unfortunate but seemingly unavoidable part of providing healthcare services, from psychiatric patients who attack nurses to irate family members going after a doctor. However, the type of violence facing healthcare organizations is changing, as evidenced by a recent report in The Journal of the American Medical Association (JAMA). The JAMA article indicates that hospital shootings are becoming increasingly prevalent, with “active shooter incidents” increasing from nine per year from 2000 to 2005, to an average of 16.7 per year from 2006 to 2011. (An abstract of the article is available online at http://tinyurl.com/q8xopy2.)

When cardiothoracic surgeon Michael J. Davidson, MD, was fatally shot on the premises of the Brigham and Women’s Hospital in Boston on Jan. 20, 2015, there had been 14 active shooter incidents in U.S. hospitals in the previous year. Fifteen people died in those incidents.

“This reality and its potential amplification by copycats has reignited the debate over the adequacy of current and future hospital security arrangements,” the JAMA report says.

Bureau of Labor Statistics data show that healthcare workers are at higher risk of workplace violence than other American workers. The rate of workplace violence-related nonfatal occupational injuries and illnesses involving days away from work for healthcare and social assistance workers was 15.1 per 10,000 full-time workers in 2012, compared to 4.0 for private industry overall.

Common factors associated with violence in emergency departments include long wait times, psychiatric patients, patients who have a history of violence, and patients under the influence of drugs or alcohol, according to a recent study in the Journal of Emergency Nursing. (An abstract of the study is available online at http://tinyurl.com/ovyzluy. For information on federal guidelines to reduce workplace violence, see the story in this issue.)

Keep prisoners restrained

The increase in shooting incidents is prompting more hospitals to conduct active shooter drills, says Ben Scaglione, director of security in healthcare for G4S Secure Solutions, a security company based in Jupiter, FL. Inova Fairfax had conducted active shooter drills before its recent incident.

Hospitals also are seeing more violence from behavioral health patients and are developing better response plans, Scaglione says. Similarly, hospitals should reassess how they handle inmate prisoners, such as the one at Inova Fairfax, he says. Handcuffs and other restraints can be a thorny issue, with clinicians sometimes insisting that a patient be released at least temporarily during treatment.

“It’s a lack of understanding. Clinical staff want the best for their patient, but the bottom line is they are prisoners and they need to be shackled,” Scaglione says. “Clinical staff need to understand that a shackled prisoner needs to stay that way. I saw a case years ago where a prisoner should have been shackled and wasn’t, and he was able to leave his room and sexually assault a female patient down the hall.”

There has been a small increase in hospitals arming their in-house security officers, he says, but that issue is contentious. Some healthcare and security experts say armed security brings with it too much potential liability and responsibility for adequately training and certifying employees. Others say armed guards are necessary because a large amount of violence can take place before local police arrive.

Arming your security guards will get the attention of your insurers also, notes Sean Ahrens, CPP, BSCP, CSC, security consulting services practice leader for Aon Risk Solutions in Atlanta, the global risk management business arm of Aon. An insurer that might be responsible for paying claims related to an employee using a firearm will demand extensive documentation of the screening, training, and certification of those employees, he says. “It takes a significant effort to maintain those records, which you absolutely must have if an incident ever occurs,” Ahrens says.

The decision might come down to what sort of neighborhood the hospital is located in and what treatment is provided, says Allan Ridings, senior risk management and patient safety specialist with the Cooperative of American Physicians (CAP), a doctor-owned medical malpractice insurance organization in Los Angeles. An acute care hospital in a high crime area, with a busy emergency department, is more likely to need armed guards than a specialty facility in a low crime area, he says.

“When I worked for a large medical corporation, we had armed guards on campus, patrolling the parking lots, even in the facilities that were not in high crime areas,” Ridings says. “An important benefit is that it lets employees know you care enough to protect them.”

What are your options?

One option is to arm only one or two senior security personnel who are trained and experienced, and another is to hire off-duty police for high-risk areas such as the emergency department, he suggests. Both strategies would reduce the potential liability. (For information on a hospital that decided against arming its security guards, see the story in this issue.)

“I know a lot of hospitals that have had armed security for years and never had a bad shooting, but if your employee discharges that weapon and hurts someone, intentionally or by accident, your liability is through the roof,” Scaglione says.

In addition to potential civil liability from shootings, risk managers should remember the risk from running afoul of expectations from the Occupational Safety and Health Administration (OSHA) regarding workplace violence, says John Ivins, JD, a partner and leader of the Health Care Practice at the law firm Hirschler Fleischer in Richmond, VA. In 2011, OSHA issued Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents, document number CPL 02-01-052, to guide inspectors. Ivins suggests that risk managers should study the document to assess compliance with OSHA’s requirements. (The OSHA document is available online at http://tinyurl.com/q9npn3h.) Failure to protect employees from workplace violence can result in a general duty clause citation from OSHA, which Ivins calls “serious, significant, and costly.”

An “A” for anticipating

Inova Fairfax did good job of anticipating and preparing for the violence, says R. Stephen Trosty, JD, MHA, ARM, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of the American Society for Healthcare Risk Management (AHRM).

“Risk management tries to be proactive, to determine actual or potential incidents that cause risk for people and facilities, and act accordingly,” he says. “To ignore the problem, and the increase in the problem, is not risk management, nor is being unprepared or incapable of responding to a potentially known risk. Safety should win out over appearance in the hospital.”

Sources

• Sean Ahrens, CPP, BSCP, CSC, Security Consulting Services Practice Leader, Aon Risk Solutions, Atlanta. Email: sean.ahrens@aon.com.
• Greg Brison, Director of Emergency Management and Security, Inova Fairfax Hospital, Falls Church, VA. Email: greg.brison@inova.org.
• John C. Ivins Jr., JD, Partner, Hirschler Fleischer, Richmond, VA. Email: jivins@hf-law.com.
• Allan Ridings, Senior Risk Management and Patient Safety Specialist, Cooperative of American Physicians, Los Angeles. Email: aridings@capphysicians.com.
• Ben Scaglione, Director of Security in Healthcare, G4S Secure Solutions, Jupiter, FL. Email: ben.scaglione@usa.g4s.com.
• R. Stephen Trosty, JD, MHA, CPHRM, President, Risk Management Consulting, Haslett, MI. E-mail: strosty@comcast.net.