“Code Green Active – Emergency Department”.

Of all the concerning codes we regularly familiarize ourselves with in the hospital – e.g., “Code Red” = Fire; “Code Pink” = Infant Abduction; “Code Blue” = Cardiac Arrest” – there is nothing more imaginably terrifying than hearing the code for an active shooter overhead. Although it is terribly unfortunate that any complex species would have to blog on such a topic (ahem – I won’t discuss the meaningless term gun control), our continuously refreshed reality, as in El Paso and Dayton, supports that we cannot blog enough about active shooters in the workplace.

Inline with the steady rise in public- and hospital-based active shooter incidents (1-3), most healthcare and hospital workers recognize that healthcare workplaces (especially hospitals) are considered “soft targets” for violence – meaning they are relatively unprotected or vulnerable to attack. In fact, similar to many public areas, there are very few hospitals outfitted with weapon or gun screening mechanisms at their front doors. One only needs to Wiki or Google “hospital shooting” to understand the landscape and find atop the list, results for Mercy Hospital’s (Chicago 2018) and Bronx Lebanon Hospital’s (New York 2017) active shooter events.  Tragically, between these two most recent hospital experiences – one fellow, three residents, and two medical students (60% of all collective victims) suffered significant injuries or death.

Although thankfully our “n” is low, the concerning statistical trend above suggests that our “learners” (aka healthcare students, residents, fellows), may be a population that is more vulnerable to the ill-intentions of hospital shooters, specifically while on their clinical rotations.  Theory points to the fact that learners tend to be the most junior and least experienced cohorts in the healthcare workspace, and perhaps the perfect storm of environmental unawareness, superficial understanding of hospital protocols/responses/codes, as well as sporadic participation in hospital simulations and drills for active shooters, may be the root cause of the observations.  Statistical assumptions aside, every person in the healthcare and hospital setting (and any workplace for that matter), needs to be well informed and prepared to respond to an active shooter.

Below you will find tips on how learners can stay safe if an active shooter presents to the healthcare workplace:

  1.  “Run, Hide, Fight“.  This particularly catchy phrase should be the first thing that comes to the forebrain when faced with an active shooter.  First priority – “Run”.  No time for deer in the headlights, finishing up a telephone consultation, or diagnosing the noises of gunshots.  This should be one of those good heuristics (aka mental shortcuts) that you always carry with you in your decision making briefcase.  Second priority – “Hide”.  Should you find yourself out of running room, attempt to hide in a secure location.  Leverage furniture or medical equipment to blockade doors, windows, and entry points – the heavier the better.  Turn off the lights, quick telephone 911 for help (time permitting), and remain silent until the situation is stabilized.  Lastly, if “Run” and “Hide” are not options – “Fight”.  This may sound like an unusual recommendation, but remember at this point it’s “either you or them” (the shooter).
  2. In order to “Run” or “Hide” – you need to know where you are going.  It is essential to have environmental awareness from day one.  During site orientation, take a moment to visualize all potential avenues of egress and places to hide in the event you find yourself amidst an active shooter code.  If this is not reviewed, be sure to ask your preceptor or direct report to go over the physical layout of the department, environment of care, and all its exit points.
  3. Know your codes.  Many hospitals and healthcare establishments have different codes for the same event.  This can be confusing especially if you are rotating at multiple sites.  If you don’t put effort into in-depth understanding of hospital codes, you are putting your safety at risk.
  4. Engage in active shooter simulations.  Healthcare administrators and safety officers invest significant time and resources into these types of drills.  However, as is the case with any learning opportunity during clinical rotations, “you get out what you put in”.  So take all simulation seriously, participate, and establish the muscle memory of how to respond to a real active shooter code.

In the end our healthcare environments continue to heal infinitely more of the sick and injured than they contribute to the sick and injured.  Our learners are essential cornerstones to the current and future healthcare infrastructure and their safety matters.  Thankfully, healthcare and hospital shootings remain extremely rare events. As such, while it is important to recognize the safety of the healthcare environment, it is equally as important to “always be prepared” and “always be safe”.

– Clinical Rotation –


1 – https://www.hasc.org/sites/main/files/03-hos1_0.pdf

2 – https://repository.library.brown.edu/studio/item/bdr%3A581443/PDF/

3 – https://www.beckershospitalreview.com/population-health/17-fatal-hospital-shootings-since-2002.html