Nov. 10, 2022
While hospital shootings are rare, they do occur, says Bryon I. Callies Jr., deputy chief security officer and trauma center operations administrator at Mayo Clinic in Rochester, Minnesota. For example, a 2018 article in The Associated Press reports four individuals died following a 2018 shooting at Mercy Hospital & Medical Center in Chicago, and a husband shot his wife at Westchester Medical Center in Valhalla, New York. In 2017, a shooting occurred at the University of Cincinnati Medical Center psychiatric services emergency room.
The 2022 International Association for Healthcare Security & Safety Foundation crime survey revealed that U.S. hospital violent crime increased significantly in 2021.
According to Campus Safety Magazine's 2022 article on the survey: "Murders, rapes, robberies and aggravated assaults increased to a record 2.5 incidents per 100 beds in 2021, which was a 47% increase compared to 2020 when the rate of violent crime was 1.7 per 100 beds. The latest findings are particularly troubling because the rate of violent crime in U.S. hospitals in 2020 was also a record."
Thus, despite the overall infrequency of violent gun incidents, the trend is increasing. Callies indicates the violence severity level also has increased throughout the COVID-19 pandemic. Accordingly, hospital threat management is crucial.
Hospital shooting motives, risks by location
Rationales differ among health care facility firearm shooters, says Callies.
"That's the challenge with active shooter incidents," he says. "There's so much variability with causation."
Risk levels at hospitals of differing sizes and locales may not vary as widely as it appears, says Callies, while acknowledging a larger population may increase risk.
"Certainly, hospitals are at risk," he says. "And perhaps they're at the same risk level, despite differences. The organization doesn't drive risk; it's the individual instigating the incident."
Though mental health crises and substance misuse play a role, Callies says hospital gun violence and random killing frequently share a common thread: unresolved grievance.
"My experience is most indiscriminate shooting is domestic violence spillover into the workplace — the hospital, in our case — and has nothing to do with the organization where the incident takes place," he says.
Callies explains while smaller, rural facilities may feel protected, he witnessed Southeast Minnesota law enforcement's rural risk perspective change upon learning that a teenager in Waseca, Minnesota, developed a mass killing plan. A couple egregious U.S. killings have occurred in rural Michigan and rural Pennsylvania. Rural communities are not immune to this type of violence.
Hospital workplace violence perspectives
Though violence in hospitals is not new, it is more recognized and addressed today, says Callies, referring to incidents ranging from active shooting to groping, verbal abuse, spitting, hitting and kicking. Threats regarding individual physicians are rare.
Health care work environment violence continues trending upward. The U.S. Bureau of Labor Statistics' data for 2011 through 2018 indicate serious workplace violence incidents were five times more likely to occur in health care than other industries, an increase from four times more likely in 2013. Callies says he cannot think of another industry that tolerates violence toward its employees as much as health care. These employees are more likely to be significantly injured from violence than law enforcement, according to the U.S. Bureau of Labor Statistics data. A common health care employee viewpoint he disagrees with is "dealing with violence is part of the job." In part a reflection of this attitude, research published in Workplace Health & Safety in 2015 showed workplace violence incidents are significantly unreported, with 88% of incidents not formally documented.
Workplace violence potential provokes anxiety for hospital employees, Callies says. He feels strongly that hospitals should not tolerate gun or other violence.
"Violence is in no one's job description," he says. "Mayo Clinic or any other hospital can't provide world-class health care when employees don't feel safe. We want to create a safe environment so our care teams can focus on patients' needs."
Callies sees proactively addressing bedside violence as key to helping employees feel safe.
Violence risk assessments provide objective bases for implementing safety plans. Behavior safety plans and health record flags with "violent" make staff aware of violent potential. De-escalation, physical defense and control training empower staff during violent situations. Terminating patients or visitors who have been intentionally violent sends a message to staff and patients that violence in the care environment will not be tolerated, Callies explains.
"Any violence simply damages relationships between patients and their care providers," he says. "It's hard to see a person through a humanitarian lens if they broke your tooth or gave you a concussion during their last visit."
Hospital violence prevention recommendations
In rural communities, Callies considers partnership building crucial to maintaining safe hospital environments. He suggests forming a community collaboration involving parties such as emergency department personnel, law enforcement, social workers, city or county attorney's office personnel, and mental health providers, as they all share aspects of the same problem. He suggests avoiding blame; instead, work together to build trusted relationships and solve complex challenges involving violence.
Callies says Global Security leads Mayo Clinic threat management. This is an evidence-based approach to address targeted physical violence threats, aiming to move an individual off the escalating violence pathway. Mayo campuses have the same security service levels, including behind-the-scenes risk monitoring.
He recommends strategies to address potential violence at your hospital:
- Develop a behavior safety plan. This plan sets patient and visitor expectations while alerting staff to violence risk. Mayo Clinic uses teal tornado-like door symbols and violet electronic health record flags to alert those caring for a potentially violent patient. Another measure to deal with patients who have demonstrated violence proclivity involves requiring security personnel to accompany them — a highly controlled environment — on campus if releasing the patient from care is not possible.
- Form a complex behavior committee. This multidisciplinary group discusses and sets policy regarding patients with complex or threatening behaviors. The group provides a forum for discussing challenging patient situations and improving the hospital's full violence management continuum.
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Perform weapons checks. Security personnel should check individuals entering hospitals for weapons and send individuals with guns or other weapons back home, to their hotels or their vehicles for storage, or offer incineration.
Mayo Clinic recently began installing entrance weapons detection systems with artificial intelligence learning functions. Entrants maintain a walking pace, with most people proceeding through without issue. Mayo plans to install more entrance detection systems. Callies says in upcoming years, no one will enter Mayo Clinic without going through security, validating they belong on campus and are not bringing weapons.
"Weapons detection isn't designed to prevent active shooters per se, but minimize weapons access. As a highly emotional environment, limiting weapons access can help minimize violence severity," he says.
Callies warns against superficial assumptions about individuals who might enter the hospital with guns or other weapons.
"Recently, a 70-year-old patient and her 90-year-old mother were carrying guns at a Mayo Clinic entrance," he says. "You can't tell just by looking at people who's carrying a gun. This makes technology an important, objective way to identify weapons."
Callies and staff have observed nearly 100% patient and visitor satisfaction while passing through the detection system. Employees' reactions have been similar.
"While it's new technology and service, once weapons screening is operational, it sells itself as valuable, given the numbers of firearms, knives and other potential weapons prevented from entering a screening location," he reports.
- Provide duress alarms and lockdowns. Callies recommends equipping units with duress alarms or panic buttons and putting personal duress alarms in designated higher volatility areas. If an incident arises, lock down the unit. At Mayo, security continually locks down the emergency department, critical care units and other units due to tensions inherent in acute care coupled with vulnerable patient populations.
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Encourage "see something, say something." Train employees to be alert to threats and to tell security personnel or a supervisor about anything concerning. Callies suggests urging employees experiencing domestic violence issues at home to seek help from hospital security.
"If others aren't aware of it, they can't help manage it," he says.
He indicates reporting is key to alert leadership about security issues, especially when the threat is at a lower level.
- Take all threats seriously. Callies encourages hospital security and leadership to give credence to all threats, even though evaluation may find them transient only. He recommends employees seek security advice for any threat.
- Determine protective actions for patients. While preventing weapons from entering the hospital is crucial, violent incident potential still exists. Callies suggests active shooter incident staff training using "run, hide, fight" actions. For more routine violence occurring in the hospital, he suggests verbal de-escalation and physical defense and control technique training.
Concluding hospital security thoughts
Callies says hospital security has evolved in recent years. "It's not so much a 'come one, come all' environment as it was before," he says. "Want to get your hair cut at the hospital barber? Do your 10,000 steps? Not so much now."
Callies feels gun violence is more a societal problem than a hospital problem, to be addressed by a collaboration of community leaders and others, with hospitals at the table as valued partners.
For more information
Fatal hospital shootings in the U.S. in recent years. The Associated Press. Nov. 20, 2018.
2022 IAHSS Foundation crime survey. International Association for Healthcare Security & Safety.
Hattersley-Gray R. Hospital violent crime increased 47% last year. Campus Safety Magazine. May 19, 2022.
Illnesses, injuries, and fatalities: Fact sheet, workplace violence in healthcare, 2018. Fact sheet, workplace violence in healthcare, 2018. U.S. Bureau of Labor Statistics.
Arnetz JE. Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health & Safety. 2015;63:200.
Refer a patient to Mayo Clinic.