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From the Dark Side: The Alarming Rise of Violence in Healthcare

In recent healthcare incidents and violent attacks that have swept the country, victims and their families have been left with unanswered questions as investigators attempt to piece together clues from the deceased suspects’ social media posts, letters, and/or manifestos and determine the motives and patterns around their fatal and horrific actions.

If a perpetrator enters your doors with the intent to harm you or anyone in your practice, the motive for their violent behavior quickly becomes irrelevant, but your response does not. One thing is clear—don’t leave the back door open.

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On June 1st, 2022, a disgruntled patient entered a Tulsa, Oklahoma orthopedic office and fatally injured four individuals, including two physicians. It is unknown whether the practice had a threat assessment or response plan. The patient was upset because of ongoing pain following back surgery. Did the patient lack understanding about the potential surgical results? Did he have underlying anger issues? Did he have unrealistic expectations for what surgery could or would do for his condition? (Read more about managing patient expectations.) Regardless, the patient likely expressed anger to some degree at some point, but the office staff and/or physician may have lacked training and failed to appreciate the risk, or worse, dismissed the patient altogether.

This is not to say certain behaviors are precursors to threatening behaviors. It simply means “pay attention.” There is a distinct difference between a patient with residual back pain who is reasonably expressive about their condition and one who utters inappropriate comments or manifests dangerous behaviors.

Regardless of the behavioral signs, the reality is that physicians and office staff must:

  •  Develop a level of situational awareness to potential threats that may present, and;
  •  Create a pre-planned and rehearsed response.

Many medical offices are particularly vulnerable spaces simply by architectural design, with a reception area open to the public from either a hallway or outside airspace, and an open window or counter for patient check-in. However, there are actions you can take to improve the security of your environment.

Josef Levy, a retired Commander with the Long Beach Police Department and president and owner of Embassy Consulting Services, LLC., offers some practical tips for making medical practices a more secure work environment.

  • Provide hands-on workplace violence/active shooter training, which is mandated by OSHA. Untrained staff will not be prepared or know how to respond to violence or an active shooter if it happens. Many people will default to duck and cover, which sadly, is the last thing they want to do. Training is critical and must be live and customized for your practice. Training should also include topics around the “Run, Hide, Fight–Active Shooter Protocol“; identifying “red flags” in patients or potential shooters; and stressing the importance of being vigilant. These are the most effective ways to deal with violence in the healthcare industry. History and statistics have told us that there are different and better outcomes for those individuals who have been trained in active shooter response versus those that have not been trained.
  • Have an expert conduct a security site assessment of your office to identify vulnerabilities and make recommendations to create a safer work environment.
  • TRAIN, TRAIN, TRAIN! Develop response plans, and regularly run practice drills. Implement an alert system, even if only a verbal shout to notify all of a threat. Situational awareness training—observing for threats and practical response patterns—will help you and your staff inside and outside of the office setting. 
  • Understand that office buildings are “projectile transparent” being made mostly of wall board affixed to thin metal studs. That means bullets will pass through and continue their trajectory until they strike solid resistance.
  • Learn the difference between “concealment” and “cover”—concealment means you're hidden, cover means you're protected.
  • Make note of patients and persons expressing or exhibiting inappropriate behaviors.
  • Conduct morning huddles with all staff members to go over the day’s events and any incidents involving inappropriate patient or individual behavior. If deemed by the office as a serious safety threat, staff should be made aware of the individual and provided with a physical description. However, caution should be taken to balance safety concerns with patient privacy rights and inappropriate profiling of individuals.

From a training perspective:

  • There are several companies that offer general workplace violence prevention training, or AB508 Assaultive Behavior Management (ABM), either in person or online. AB508 ABM training is required for hospital staff working in certain high-risk areas. The length and costs of these programs can vary.
  • Many local, state, and federal law enforcement agencies offer free online education for surviving an active shooter incident. Instruction manuals and YouTube videos, some as short as seven minutes, are available. Unfortunately, some of the videos are graphic, but they get the “Run, Hide, Fight” message across. Multiple resources are available by performing a quick internet search of active shooter training or prevention.

From a hardware perspective:

  • Door locks - Is your pass door from the reception area to the back office secured? Can it be inadvertently left unlocked? Is it reinforced to resist being forced open from the reception area? This is where you want a solid, not hollow, door. Electronic locks work well when controlled from the reception area.
  • Design your reception area to make it harder to enter the back-office area. Open air designs are attractive but make it easy for an attacker to jump over the counter.
  • A safe zone - Do you have a designated area where staff can gather? A place that can be secured with a reinforced solid door? Your break room may be a viable option. An alternative is an escape method such as rear exit, especially one with quick access to stairs or the outside. 
  • Active shooter situations and violence in the workplace and beyond are difficult topics to address, but it is better to be prepared before it is too late. If you’re interested in having a security assessment of your office, please consult the CAP Marketplace's Safety and Security vendors.   

Lee McMullin is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to