American Association for Physician Leadership

Strategy and Innovation

What Is the Healthcare Provider’s Role in an Active Shooter Incident?

Debra Cascardo, MA, MPA, CFP

December 8, 2018


The reality of the modern world is that we all must be prepared for the worst. By outlining policies and procedures for any situation, you take the first step in this preparation. Training all staff in these procedures and role-playing possible situations can help reactions become second-nature, eliminating confusion if a disaster occurs. Educate your staff on the importance of timely communications in order to get the data necessary—home, cell phone, personal email, and so forth—to keep them informed. Timely communication could make the difference between life and death.

Although I have previously written several articles on disaster preparedness, attention must now be focused on a special type of disaster that seems to be in the headlines more and more—the active shooter. Unfortunately, medical practices are not immune to gun violence, and closing your eyes and hoping it never happens to you is not an option. Although you cannot prevent random acts of violence, being prepared and knowing how to respond to an active shooter is the key to survival.

As with all disaster preparedness, planning and training are key components that will enable you to react effectively to the situation. Every practice should have comprehensive policies and procedures to address both protection of personal health information and also the continuity of clinical care during an emergency—regardless of whether the cause of the emergency is natural or manmade. No matter the type of disaster, advance planning and training are the keys to maximizing the safety of your staff and patients and ensuring the continuity of your practice.

During an active shooter situation, the natural human reaction is fear and anxiety.

Organizations such as schools, government facilities, and business office settings have developed plans to address active shooter incidents. It’s time to pull out your disaster preparedness plan and add a section on how to respond if faced with an active shooter scenario. You should have a section called Active Shooter—Emergency Preparedness Compliance Plan.

During an active shooter situation, the natural human reaction is fear and anxiety. There will be noise from gunfire, alarms, and shouting. Patients will be in disbelief, panicking and screaming. Training will allow staff to act despite the chaos. Ideally, training will provide automatic responses so staff members act instinctively according to their training rather than descending into denial and helplessness.

The content of your disaster preparedness plan regarding an active shooter incident depends on the size, type, location, and so on of your practice or facility. Is yours a small practice or a large facility? Is it in an urban, suburban, or rural setting? Are patients ambulatory, critical care, or acute care? Is there security or law enforcement on the premises or nearby?

Duty to Care

Basic to the healthcare professionals’ credo is the duty to care for the patients for whom they are responsible. Any disaster can become a highly dynamic situation requiring some ethical decisions to ensure the least loss of life possible. Every reasonable attempt to continue caring for patients must be made, but in the event this becomes impossible without putting others at risk for loss of life, certain decisions must be made.

Resources must be allocated fairly, with special consideration given to attending to those most vulnerable and limiting harm as much as possible. If resources are limited, healthcare professionals may not be able to meet the needs of everyone. However, all patients must be treated with respect and dignity, regardless of the level of care needed or available. You may be forced to discontinue care to those who cannot be brought to safety in consideration of those who can be saved.

Some individuals who could have avoided the incident may choose to remain in dangerous areas. To the extent possible, consider the greater good and think about the needs of others as well as yourself.

Adding an “Active Shooter” Section to Your Disaster Preparedness Plan

Because healthcare practices vary in many ways, your disaster preparedness plan should consider all of the following points but incorporate only those that meet your individual circumstances, keeping in mind these common principles:

  1. Seek to maximize the protection of life.

  2. Strive to evacuate as many as possible from harm’s way.

  3. Acknowledge that decisions may have to be made based on personal assessment of the situation.

  4. Recognize that a decision to engage or fight the shooter may have to be made.

  5. Include the duty of care for patients and the best action to take to maximize the protection of life.

Recognizing a Potential Active Shooter

Although no profile exists to identify a potential active shooter, there are some known indicators. Warning signs that an individual may become an active shooter include these common pre-attack behaviors(1):

  • Pathway warning behavior: any behavior that is part of research, planning, preparation, or implementation of an attack.

  • Fixation warning behavior: any behavior that indicates an increasingly pathological preoccupation with a person. It is measured by:

    • Increasing fixation and/or concentration on one person and/or event

    • Increasingly strident opinions;

    • Increasingly negative characterization of the object of fixation; and

    • Impact on the family or other associates of the object of fixation, if present and aware.

  • An angry emotional undertone: typically accompanied by social or occupational deterioration;

  • Identification warning behavior: any behavior that indicates a psychological desire to be a “pseudo-commando,” have a “warrior mentality,” closely associate with weapons or other military or law enforcement paraphernalia, identify with previous attackers or assassins, or identify oneself as an agent to advance a particular cause or belief system.

  • Novel aggression warning behavior: an act of violence that appears unrelated to any targeted violence pathway that is committed for the first time. Such behaviors may be used to test the subject’s ability to actually commit a violent act.

  • Energy burst warning behavior: an increase in the frequency or variety of any noted activities related to the target, even if the activities themselves are relatively innocuous, usually in the days or weeks before the attack.

  • Leakage warning behavior: communication to a third party of intent to do harm to a target through an attack.

  • Last resort warning behavior: evidence of a violent “action imperative,” increasing desperation or distress through declaration in word or deed, forcing the individual into a position of last resort. The individual feels that there is no alternative other than violence and that the consequences are justified. The subject feels trapped.

  • Directly communicated threat warning behavior: communication beforehand of a direct threat to the target or to law enforcement. A threat is a written or oral communication that implicitly or explicitly states a wish or intent to damage, injure, or kill the target, or individuals symbolically or actually associated with the target.

  • Other warning signs may include situations such as the following:

    • An employee confides that she or he is going to commit suicide;

    • An employee starts crying once or twice a week for no apparent reason and without provocation; or

    • A female coworker who is going through a divorce gets a call from her estranged husband who says he coming over to kill her.

Preparing for an Active Shooter Situation

The “active shooter” section of the disaster preparedness chapter of the healthcare facility’s procedures and policies manual should contain goals, objectives, and courses of action. These plans will be affected by the assessments conducted at the outset of the planning process and updated as ongoing assessments occur. Include input from all stakeholders, including executive leadership, legal, nursing, security, facility engineering, human resources, emergency management, risk managers, and local law enforcement. You need to create a clear workplace violence policy and plan that you share with your local hospital, police, and fire department. Give them a draft and have them offer suggestions.

The plan should provide detailed descriptions of the following actions to take during an active shooter situation:

  • A preferred method for reporting active shooter incidents;

  • A system for how persons at the healthcare facility or campus will be notified when there is an active shooter on campus:

    • Such notifications could be done through the use of code words, sounds, lights, and electronic communications, such as text messages or e-mails. Include means of communicating with those who have language barriers or need other accommodations, such as visual signals or alarms to advise deaf patients, staff, and visitors about what is occurring.

    • Healthcare facility-wide “reverse 911” text messages can be sent out to a pre-established group distribution, especially if there are individuals at remote locations within the premises and other campus buildings.

    • The plan should include procedures for notifying local law enforcement and emergency responders.

  • An evacuation and lockdown policy and procedure:

    • Effective shelter-in-place locations that have thick walls, solid doors with locks, minimal interior windows, first-aid emergency kits, communication devices, and telephones or duress alarms;

    • Clearly defined emergency escape procedures and route assignments (e.g., floor plans, safe areas);

    • Clearly described procedures for evacuating or locking down patients, visitors, and staff. Information should be included on how to evacuate when the primary evacuation routes are unusable; and

    • Lockdown procedures for individual units and locations and other campus buildings. These should be described individually.

  • Attention to access and functional needs when advising on shelter sites and evacuation routes;

  • Integration with the facility’s emergency operations plan;

  • Incident command system information regarding local area emergency response agencies and hospitals (e.g., name, telephone number, and distance from your location); and

  • A method of notifying patients, visitors, and staff that buildings and campus grounds are safe.

Facility Security

In addition to the “active shooter” section of the disaster preparedness policy, facilities must have a security plan.

  1. Ensure that all staff properly display an acceptable identification badge.

  2. Create a culture of safety by empowering staff to report unusual or suspicious activity.

  3. Ensure locked doors remain closed and locked.

  4. Establish a system so that doors with keypad access have their codes changed at specified intervals and codes are given only to employees with a need for access.

  5. Foster a respectful workplace.

  6. Be aware of indications of potential workplace violence and take remedial actions accordingly.

  7. Empower employees who come in contact with individuals who seem lost or are obviously not familiar with their surroundings to be helpful and ask if they can be of assistance.

  8. Make sure the plan includes information security processes, including compliance with HIPAA.


The reality of the modern world is that we all must be prepared for the worst. By outlining policies and procedures for any situation, you take the first step in this preparation. Training all staff in these procedures and role-playing possible situations can help reactions become second-nature, eliminating confusion if a disaster occurs. Educate your staff on the importance of timely communications in order to get the data necessary—home, cell phone, personal email, and so forth—to keep them informed. Timely communication could make the difference between life and death.

Every practice needs a clear policy regarding violence in the workplace. It should include what systems are in place to react to such an incident and guidance on how threats and incidents are to be managed. Develop a relationship with local law enforcement agencies. Once you have a working draft, share it with them and request their insight into the plan. Remember, it is a team effort.


  1. Meloy GD, Hoffman J, Guldimann A, James D. The role of warning behaviors in threat assessment: an exploration and suggested typology. Behav Sci Law. 2012;30:256-279. DOI: 10.1002/bsl.999.

2018 Disaster Checklist

It’s been years since Hurricane Katrina and SuperStorm Sandy. Although that is good news, it also means that people aren’t thinking about preparedness, supplies in survival kits are stale or expired, and contact lists may not include current information.

Every day we see news about severe storms and wildfires. Is your family prepared? How about your business? You need supplies for all the possible people you will have to shelter. Make sure you have enough.

Please share this with your family and business associates.

Family/Business Communications Plan

  • Write down critical cell and landline numbers in case your phone dies.

  • Know where your family members or business colleagues will meet if cell towers and landline phones go out.

  • Designate an out-of-area relative everyone should contact if they can’t reach each other.

  • For your business, complete a contact sheet for all workforce members, including their personal e-mail address, their spouse/partner contact info, and an out-of-area contact you can call if you can’t reach your employee.

Water. Water systems may be contaminated and unsafe for three or more days.

  • Buy cases of water or fill pots and pitchers with drinking water. Allow 1 gallon per day per person.

  • Store 10 gallons of clean water for cooking.

  • Use food-grade water containers from camping stores.

  • Replace the water every six months if not using commercially bottled water.

  • Never use water from toilet flush tanks or bowls, radiators, waterbeds, or swimming pools/spas for drinking, bathing, or cooking.

  • Purchase a purifier to filter contaminated water.


  • Store nonperishable food you don’t have to cook.

  • Include food needed for special diets.

  • Store nonperishable food for your pets.


  • Know how to turn off your electric, water, and gas services.

  • Keep necessary tools near your shutoffs for quick action.

  • Never turn on your utilities until authorized.

  • Always have a professional turn your gas back on.

Cash. Credit cards won’t work if power and communications go down.

  • Withdraw $200 to $300 in small bills so you can make cash purchases.

Automobile. Gas pumps won’t work if the power fails.

  • Fill your gas tank when you first hear a warning.

  • Don’t drain your car battery by using it to charge cell phones or other devices.

  • Keep an emergency kit in your car in case you are stranded away from home.

Cell phones

  • Register your cell phone to receive calls from your county’s emergency management system.

  • Install weather and disaster preparedness apps and configure for alert notifications.

  • Text messages use less battery and get through when calls can’t

  • Photograph the contents of your house or business every 6 months or after major changes.

  • Store emergency contact info for family members and employees, including alternate e-mail contacts and phone numbers for their close friends and relatives in case you can’t reach them directly.

  • Bring external batteries to keep your cell phone powered. Keep them charged.

  • Pack your car charger and home charger if you evacuate.

Debra Cascardo, MA, MPA, CFP

Principal, The Cascardo Consulting Group, and Fellow, New York Academy of Medicine; phone: 914-358-9553; fax: 914-358-9554; e-mail:

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