A few years ago, one of our physicians was threatened by a patient who said he was “…going to come after you with my gun” because she refused to prescribe opioid pain medications for him. She was very distraught and came to me looking for measures to keep her safe in the workplace. In the past week, there have been several homicides at American healthcare facilities that have caused me to think back to that doctor.
Doctors and nurses facing the wrath of angry patients and their families is nothing new. Thirty-five years ago, when I was a fellow in training, a woman sent our division a letter saying that she was going to come to the hospital to kill all of the pulmonary and critical care doctors with her automatic rifle because her husband had died in our ICU. I had never even met her or her husband. What is different today compared to 35 years ago is that weapons are much more easily available and America has increasingly developed a culture of gun violence.
In the latter half of the last century, the United States was embracing greater degrees of gun control. In 1967, then governor Ronald Reagan signed the California Mulford Act that prohibited the public carrying of loaded firearms without a permit; violations were subject to a felony. At the time of signing, Reagan famously said that there was “…no reason why on the street today a citizen should be carrying loaded weapons”. The Mulford Act was notably supported by the NRA, which at the time was an organization primarily focused on the recreational use of guns and on gun safety. In 1993, the Brady Bill required mandatory criminal background checks on anyone purchasing firearms. In 1994, the Violent Crime Control and Law Enforcement Act banned the sale of assault rifles in the U.S.; the law had a 10-year limitation and expired in 2004. However, over the last 15 years, due largely to lobbying by special interest groups that promote gun availability, weapon laws have been rolled back. Coincident with this has been an increase in gun deaths, mass shootings, and healthcare shootings. Prior to the 1994 assault rifle ban, there were an average of 7.2 mass shooting deaths per year in the U.S. During the ban, that number dropped to 5.3 per year. After the ban expired in 2005, the average number of mass shooting deaths rose to 25 per year.
Shootings at healthcare settings
An FBI report found that there were 13,927 U.S. homicides in 2019. Firearms were by far the most commonly used weapons, accounting for 73% of the homicides.
Semi-automatic rifles (such as the AR-15 rifle) loom large in the public perception of homicides, largely due to their use in high-profile mass shootings. However, handguns are by far the most commonly used weapons in American homicides and account for 91% of firearm-related homicides. Firearms are also the method of choice for suicide in the United States and account for 53% of deaths by suicide per CDC data.
The CDC reports that in 2020, the firearm-related homicide rate was the highest that it has been in more than 25 years with a 35% increase compared to 2019. Overall, 45,222 Americans died from firearms in 2020. There have been a total of 18,882 gun-related deaths so far this year in the U.S. which puts us on a pace to exceed the 2020 number – and we have not even reached the busy summer homicide season. There have been 247 mass shootings so far this year and last Wednesday, there were fatal shootings at hospitals in Tulsa, OK and in Dayton, OH. Last Saturday, a physician and 2 nurses were stabbed in an emergency department in California. Our hospitals are becoming increasingly dangerous – The International Association for Healthcare Security and Safety reports that there was a 47% increase in hospital violent crimes in 2021 compared to 2020.
Violence against healthcare workers is incredibly common. According to the Bureau of Labor Statistics, healthcare providers account for 73% of all workplace injuries due to violence. A hospital is one of the most dangerous places to work in the United States.
In a 2017 study of 346,343 emergency department visits, weapons were found in 3% of all ER visits with a total of 10,691 weapons confiscated at screening. Weapons were most likely to be found at hospitals that provide trauma and behavioral health services. Knives were the most common weapons found.
Hospital shootings are relatively rare but are usually widely publicized resulting in a greater awareness of shootings compared to other violent acts at hospitals. A 2012 study found that there were 154 shootings at healthcare facilities between 2000 and 2011 (12.8 per year). A more recent study found that there were 88 hospital shootings at healthcare facilities between 2012-2016 (17.6 per year). These data indicate that the annual number of hospital shootings is increasing.
What can we do to keep our healthcare workers safe?
There is no single best answer to this question because each healthcare setting is unique. Measures that are effective in an emergency department may not be practical nor effective in a free-standing medical office. Here are some of the steps that we took to improve healthcare worker safety in our own hospital and clinic building.
- Listen. When a doctor or nurse says that a patient has threatened them, take them seriously. Even if you believe that the threat is minimal, the person who has been threatened feels vulnerable and experiences trepidation. Take every patient threat seriously.
- Encourage reporting. Far too many violent incidents and threats in our nation’s hospitals go unreported. The most common reasons are (1) fear of retaliation, (2) lack of a clear reporting method, and (3) belief that nothing will be done. Reporting should be simple and easy. Ideally, there should be multiple options for reporting – by phone, email, on-line, in-person, etc.
- Engage hospital security. Keeping patients and employees safe is what they are trained to do. The security staff will have ideas about threat assessment and threat mitigation that you have not even thought about. For smaller, private medical practices that are not affiliated with a hospital, having on-site security personnel is not feasible. However, a healthcare security consulting company may be able to at least advise options for reducing the risk of staff being harmed.
- Video surveillance. Cameras can relatively easily be installed in parking areas, entryways, lobbies, and main corridors. Because the emergency department is the location of frequent violence against healthcare workers, extra cameras in the ER are generally warranted. In large hospitals, it is often optimal to have a member of the security staff continuously monitoring video feeds. Constant monitoring by a staff member may not be practical in a smaller outpatient office but video recordings can be very useful to substantiate threats if police become involved and signage announcing video surveillance can serve as a deterrent in some cases.
- Weapon-free zones. We have signs in our hospital and clinic building entrances stating that guns and other weapons are not permitted on premises. These signs are useful to make the hospital staff and general public feel safe but do very little to prevent a person from bringing a weapon inside. I was taught to recognize concealed guns carried by visitors to our ICU and have frequently identified people walking in with a handgun. In my outpatient pulmonary practice, I have unexpectedly encountered many holstered handguns during my auscultation of patients’ lungs from their backs. In Ohio, anyone can now carry a concealed handgun with no training or permit required and so I anticipate that even more people will ignore ‘No Guns Allowed’ signs.
- Limit door access. When our outpatient doctor was threatened after refusing to prescribe opioids, we put ID badge-access locks on the doors leading from the lobbies to the patient care areas. This required any patient or visitor to be escorted by an office staff member with badge access. We periodically receive threats from family members of ICU patients and so we have installed similar badge-access door locks to the ICU as well as other vulnerable locations such as the operating room and the emergency department. Creating this type of entrance barrier to an angry person with a weapon is one of the most effective preventive measures that we can take.
- Interior design. No only should staff have easy access to exits, but staff also need to know where all possible exits are. Mirrors and strategic positioning of reception desks can improve line-of-sight in corridors and lobbies. Interior spaces and parking areas should have adequate lighting. Enclosing reception desks can create a barrier to accessing adjacent patient care areas.
- Metal detectors. These are not practical at every hospital or outpatient office entrance. However, we do use metal detectors at our emergency department public entrance and the number of weapons that are found is astounding. This requires a security staff member to be stationed at the metal detector. It is not possible to use a metal detector at ambulance entrances to the emergency department so patients brought by ambulance must be manually searched or checked with a hand-held metal detector on arrival – this is particularly necessary for trauma and psychiatric patients arriving by ambulance since these patients are more likely to have weapons.
- Panic buttons. These are devices that can be placed in a physicians office or can be carried by the physician (or nurse) that send a signal directly to the security staff if the physician (or other healthcare worker) is confronted by a threatening person. We have frequently provided these to doctors who have received threats from patients, patient family members, or former employees. The won’t stop the first bullet from a gun but they might prevent the second bullet from being fired.
- Phone call code phrases. This is a simple measure that every hospital should utilize. Staff are taught that if there is person making a threat in their area, the staff call the security office and state the code words. In order to protect the safety of our own hospital’s staff, I won’t say what our code phrase is. But choose something that won’t be obvious to the general public such as “Please page Dr. G”. The code phrase then triggers security staff to immediately go to the location of the phone call.
- Run, Hide, Fight. Active shooter training should be available to every healthcare worker. The Ohio State University uses the Run, Hide, Fight procedure for students, faculty, and staff. We require Run, Hide, Fight training for some of our hospital employees and make the training optional for others, depending on the hospital location where they work. For an example of what the training involves, watch this short video created by the FBI.
- Safety training. In situations less emergent than active shooter situations, other tactics should be used. All staff should be trained to identify warning signs and escalating behaviors that can precede a violent assault. Training should also include de-escalation techniques, available alarms, behavior control methods, and location of safe areas. Free self-defense training is often seen as a valuable fringe benefit by healthcare workers.
- Involve the police. When a doctor receives a credible threat, contact the police. Be sure to save any evidence such as letters, emails, voicemails, or video recordings. Encourage staff to press criminal charges when appropriate. This may require financial support for legal assistance as well as paid time off for legal proceedings.
- First name ID badges. This is usually impractical for physicians who by necessity need ID badges stating their last names. But patients and visitors generally do not need to know the last names of nurses and other hospital employees. Instead of their ID badge reading “Carol Smith, RN”, consider having the ID badge simply read “Carol RN”. Identity concealment can be an important deterrent to a vindictive patient.
- Parking lot escorts. Any hospital employee who feels unsafe should have the option of being escorted by security staff from their car to the building and from the building to their car. Parking lots and parking garages are second only to the emergency department in numbers of violent assaults in hospitals.
- Provide counseling. A violent assault or the threat of violence is extraordinarily stressful for hospital staff. Unaddressed, this emotional stress can result in reduced employee performance, absenteeism, and employee resignation. Counseling should be available to staff through free employee assistance programs. Hospitals and large medical practices may be able to use internal resources such as social workers and mental health providers. Small medical practices may need to establish a relationship with private counselors.
People with weapons kill people
Gun control advocates often say “Guns kill people”. Gun rights advocates counter by saying “Guns don’t kill people, people kill people”. I think they are both wrong: people with weapons kill people. Guns just happen to be America’s weapon of choice. The United States has, by far, the highest gun-related homicide rate of all high-income countries. Our healthcare facilities are not immune to homicide and other forms of violence. Doctors will always be blamed by some people for their pain, for the outcome of their illness, or for the death of a family member. Our job as hospital leaders is to create a safe workplace so that our doctors can improve people’s lives without having to worry about losing their own.
June 8, 2022