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Active Shooter at Work: How to Prepare

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Contact Hours: 3

This educational activity is credited for 3 contact hours at completion of the activity.

Overview

Gun violence is ever present, and as a result, active shooting incidents are on the rise. The Federal Bureau of Investigation (FBI) defines an active shooting event as one where an armed individual is killing or attempting to kill people in a building or specific area with any firearm, such as an assault rifle. This course will discuss the various factors that influence active shooter events in healthcare settings, the profile of an active shooter, and how facilities and individuals can prepare and develop a plan of action to minimize the danger.

Course Objectives

Upon completion of the independent study, the learner will be able to:

  • Define an active shooting event as described by the Federal Bureau of Investigations.
  • Discuss factors that influence active shooter events
  • Identify behaviors of a potential active shooter
  • Review how healthcare staff can prepare for an active shooter event
  • Understand steps to improve survival in an active shooting

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
Active ShooterAn active shooter is an individual engaged in attempting to kill people in a confined space or populated area. 
AggressionHostile, injurious, or destructive behavior or outlook especially when caused by frustration.
Directly Communicated Behavior is written or oral communication explicitly stating the intent to kill, hurt, and harm others.
Energy Burst BehaviorA marked increased frequency or variety of activity.
Fixation BehaviorCharacterized by increasingly strong opinions, especially for a person or a cause.
Identification BehaviorIs like a warrior mentality where the suspect may desire to be a commando.
Leakage BehaviorGives evidence of impending violent action.
Novel Aggression Behavior Is an act of violence that is out of place or uncharacteristic.
Pathway BehaviorInvolves intense planning, research, and preparation.
Introduction

In the US, gun violence is ever present, and as a result, active shooting incidents are on the rise.1 The Federal Bureau of Investigation (FBI) defines an active shooting eventas one where an armed individual is killing or attempting to kill people in a building or specific area with any firearm, such as an assault rifle.1 This person may be acting alone or with others and may or may not have a specific target. In either case, the active shooter has the intent to harm as many people as possible and often aims at any person in their path.2 This clearly destructive intent sets active shooter events apart from single-firing incidents and accidental discharging of firearms. Additionally, an individual carrying a firearm is not considered an active shooter until such intent is clear.1,3

Of the hundreds of shooting incidents in the past five years, the FBI has classified more than 200 of these as active shootings.1,4,5 Specifically, 6 of these have occurred in healthcare facilities from 2018 to 2022.6,7,8,9,10 Despite the low incidence, each of these events had the potential for disastrous outcomes, given the presence of vulnerable patient populations, hazardous materials, and equipment. Without adequate training and preparation, these factors can add to the unpredictability of such an event and rapidly escalate the scale of damage if not managed as quickly as possible.10

This course will discuss the various factors that influence active shooter events in healthcare settings, the profile of an active shooter, and how facilities and individuals can prepare and develop a plan of action to minimize the danger.

Active Shooters in Healthcare Settings

Given the comparatively lower number of active shooter incidents, identifying meaningful patterns about active shooters in healthcare settings is difficult. However, widening the scope and analyzing all healthcare-based shootings provides valuable insight into vulnerable areas, targeted individuals, and outcomes.

Analyzing cases from 2000 – 2016, there have been 242 active firearm incidents in healthcare facilities, with 50% of these caused by a security officer’s firearm, either stolen by the shooter or used to stop an attacker.4,5 Emergency departments were found to be the most common location for shootings, followed by outpatient clinics, parking lots, and patient rooms respectively.

In these circumstances, the victims were the active shooter and one target. Only 10% of shooting incidents had more than three victims. In 60 – 80% of cases, the innocent bystander was usually a physician, nursing staff, or patient within the vicinity.4,5 After shooting their primary target, 50% of attackers commit suicide, resulting in less than 10% being apprehended alive.11

Intentions for Shooting

Law enforcement agencies cite several types of intent for workplace active shootings: 12

  • Criminal Intent
  • Domestic Or Intimate Partner Violence
  • Ideological Views
  • Personal Grudges Against an Employee or Visitor

This classification also holds for healthcare workplaces, as each of the six specific cases falls into one of these categories.

A personal grudge against a specific healthcare provider seems to be the most common reason for the shooting, as two incidents occurred because the shooter was dissatisfied with care.9,10 On February 10th, 2021, a 67-year-old male shot five people and killed one employee at Allina Health Clinic in Buffalo, Minnesota.9

During the attack, the shooter also discharged three pipe bombs. While only two exploded, it caused considerable damage to the facility. Once police apprehended the shooter, he confessed that the doctor he killed had stopped his opioid medication, leading him to the attack.13 While the doctor may have been right in his decision to stop the medication, this incident highlights how doctors, especially those treating patients on addictive drugs, quickly become targets.14

A similar reason was also seen in a 2022 active shooter incident when a 45-year-old male opened fire at Saint Francis Hospital in Tulsa, Oklahoma, on June 2nd. 10 This shooter killed four people, including three doctors. An unspecified number of bystanders were also injured when he opened fire.

After killing his target, the shooter committed suicide. Upon investigation, it was found that the shooter targeted the surgeon who operated on him prior. After the operation, the shooter complained multiple times to the doctor about unmanageable pain and felt the doctor had not done enough to manage it. Feeling the surgeon had ruined his life, the shooter took his revenge.15

While both these cases involved patients who were under treatment, individuals refusing treatment can also pose considerable danger, as seen in a February 2019 incident when a 59-year-old male was in the process of being involuntarily admitted for mental health treatment at the Veterans Affairs Medical Center in West Palm Beach, Florida. The shooter opened fire on medical personnel, injuring two. The shooter was overpowered by nearby staff who were able to restrain the shooter until law enforcement arrived.7

Personal grudges can also involve an employee or a relation to an employee, as seen in the two following events. The first was a June 2017 shooting.16 A 45-year-old male doctor opened fire at Bronx Lebanon Hospital, his former workplace, where he had been fired because of sexual harassment allegations.16

Claiming unjust termination of employment, the shooter killed another doctor and wounded six others, none of whom had any involvement in the allegation or his being fired. While the shooter may have had a target, he demonstrated his intent to harm bystanders, as seen in other workplace active shootings.

A similar situation occurred in November 2018, when a 32-year-old male shot his former fiancé and an emergency room (ER) physician in the parking lot of Mercy Hospital & Medical Center in Chicago, Illinois.6 Once he had killed his targets, he proceeded into the building, where he shot two more people before committing suicide.17

The final reason an active shooter targets a healthcare facility is an extreme ideological view that convinces the shooter to harm people or property. Religious zealots, activists, and conspiracy theorists are among those most likely to resort to this type of violence. In November 2015, a Planned Parenthood Clinic in Colorado Springs, Colorado, was targeted for this reason.18 A 57-year-old male with staunch anti-abortion beliefs stormed the clinic and opened fire. Even though law enforcement was called immediately, the standoff lasted 5 hours, and the shooter was only apprehended after law enforcement forcefully entered the building. Nine people were injured, and three were killed.19

Preparation for an Active Shooting

Preparing for an active shooter is critical in a healthcare setting, not only to prevent deaths and injuries but also to keep the facility operational, especially if patients are admitted, or surgeries are underway. If an active shooter is intent on causing chaos, areas such as emergency departments become prime targets. Any incident in an ER can paralyze life-saving care resulting in a higher number of deaths.11

While there is no question that active shooter preparation can save the lives of every person on the premises, it is also important to remember that it can minimize financial damage for survivors. There is limited knowledge of the exact monetary burden of gun injuries, because of the lack of federal databases, although it is understood that the initial cost to treat victims is high.20

According to a John Hopkins study on the costs associated with firearm-related injuries from 2006 – 2014, emergency treatment costs averaged $5,254 per person, while average inpatient care was a staggering $95,887 per patient.21 Then the costs keep mounting after initial care as survivor studies show that medical spending for gunshot victims average $30,000 after the first year of injury, nearly four times more than medical spending for patients without firearm injuries. Yet this is a conservative estimate as mass shooting incidents also include the medical costs to treat injuries sustained by bystanders fleeing the scene.20 

Furthermore, the costs of an active shooter go beyond medical treatment.20 There is also the considerable cost associated with repairing property and replacing equipment that may be damaged during an open fire event, which can strain a facility. While active shooter events often do not last long, averaging approximately 19 minutes, every extra second an active shooter has because of a delayed response gives them time to wreak havoc on medical equipment worth millions of dollars.11

The consequences of an active shooter are severe and costly in any workplace, but in a healthcare setting, the consequences can be greater because of the unique characteristics present such as being open, accessible spaces with multiple entrances and limited restrictions. Even if law enforcement is on the premises, it can take time for them to reach and restrain an attacker.22 Additionally, these facilities often have dynamic work environments, which make it harder to spot suspicious individuals promptly – a problem that becomes more complex the larger the healthcare facility is. This scale also means numerous bystanders (patients, doctors, visitors, and other employees) can get caught in the crossfire, increasing the chances of injuries and casualties.22

Taking these specific considerations in mind, healthcare workplaces should develop comprehensive response plans and protocols that define how personnel should react in such active shooter events. Every employee across the organization should be trained to follow the plans. Important features to define include an evacuation plan for all on-site individuals, including multiple escape routes and a policy for securing immobile patients.1,2 Additionally, a swift reporting protocol must be clarified, including a notification system that alerts all staff and communicates the situation to outside law enforcement. Finally, extensive survival training is critical for on-site personnel to protect themselves and the bystanders around them.1,2

Active Shooter Behaviors

Currently, there is no clear profile of an active shooter.1 However, researchers have studied the behaviors and patterns of previous offenders to identify certain traits, observable behaviors, and signs that are prevalent among active shooters. With an understanding of these behaviors, healthcare personnel are more capable of recognizing potential workplace threats and can act proactively before the situation escalates.2,3

According to federal agencies and psychological analysis, the most common warning behaviors that indicate intent to harm others are pathway, fixation, identification, novel aggression, energy burst, leakage, and direct communication.23,24

Pathway behavior involves intense planning, research, and preparation. A suspect may be seen to visit the facility regularly or more frequently than others. They may be seen studying facility pathways and staff scheduling, unlike other patients.23,24

Fixation behavior is characterized by increasingly strong opinions, especially for a person or a cause. Often this fixation is increasingly negative, and there may be angry emotional undertones, usually with social or employment deterioration.23,24

Identification behavior is like a warrior mentality where the suspect may desire to be a commando. They frequently associate with weapons, military, or other law enforcement paraphernalia. Moreover, they may show interest in previous active shooters, even identifying with them. Additionally, they may see themselves as an agent for a belief system or cause.23,24

Novel aggression behavior is an act of violence that is out of place or uncharacteristic. It may appear unrelated to previously targeted violent warning behavior and is usually committed for the first time.23,24

Energy burst behavior is a marked increased frequency or variety of activity. These may seem harmless and resemble general activities like errand running. This behavior usually occurs in the days leading up to the attack.23,24

Leakage behavior gives evidence of impending violent action. It typically comes with increased desperation or distress through words and deeds. The suspect may indirectly communicate feeling trapped or forced into a position of “last resort.” Such feelings promote the belief that there is no alternative but violence; hence it is justified.23,24

Directly communicated behavior is written or oral communication explicitly stating the intent to kill, hurt, and harm others.23,24

When analyzing active shooters who have targeted healthcare facilities, studies have shown that these individuals are often personally associated with their main target in some way and often distressed but incredibly determined, having pre-planned their attack and accepting their fate that they will not survive. It is critical to note that this type of mindset is what makes it almost impossible to talk active shooters out of attacking.11

Signs of Aggression and Potential Workplace Violence

Along with the warning behaviors described in the section above, there are other subtle signs of aggression every person should  look out for in their healthcare workplace, in co-workers, patients, and visitors.11 Among patients and visitors, be wary of erratic and irrational behavior, especially after grief-inducing events such as an unfavorable diagnosis or ineffective treatment. Extreme statements threatening to harm themselves or others, including those of revenge or retribution, should ring alarm bells. These instances must be communicated through the proper channels so security measures can be taken to increase vigilance. It is important to note that not all signs are verbal. Auditory sounds and body language that indicate menacing or antagonistic behavior may also give away an individual’s intent to harm others.11

Among co-workers, be aware of the claim of being marginalized by friends and colleagues or unjust treatment. Any dramatic negative changes in personality or changes in workplace performance, particularly deterioration, may indicate annalistic thinking or hatred toward colleagues or the workplace. Such cases are often accompanied by sudden changes in home life, such as the ending of a long-term relationship or moving out.11

It is also important to be aware of individuals who appear in a location that is restricted for them, such as a visitor or patient in staff-only areas, or harass healthcare personnel, patients, or visitors. An individual with no proper identification or clear purpose within the healthcare facility may have detrimental motives. Any person who presents with these behaviors should not be ignored and must be removed from the unauthorized area for the safety of everyone in the workplace.11

Preparation Through Active Training Exercises

There is a great deal of uncertainty in an active shooter situation, with conditions changing minute by minute. There are always loud noises from gunfire, screams, explosions, and alarms which combine to create a highly stressful environment. It is natural for anyone in this situation to feel fear, anxiety, stress, and disbelief. In such a mental state, it is impossible to calculate risks and make rational decisions, which can result in unwanted outcomes.2,3

Active training exercises teach healthcare employees how to fight their initial reactions and regain their composure in an active shooter event so they can act logically. These exercises are in-depth, immersive experiences that educate and evaluate an individual’s ability under stress. They begin with an introduction that communicates the emergency action plan, and after the training there is a debriefing that identifies knowledge gaps regarding pertinent topics such as identifying aggressive behavior, recognizing the sound of gunshots, and how to protect oneself and dial 911 in an active shooter situation.2,3

The other aspect of this training is conducting drills that demonstrate a survival mindset and reinforce rational actions. Participants learn how to evacuate quickly, secure patients and continue providing care when necessary.

Participants also learn how to effectively barricade departments and patient rooms and hide from an active shooter roaming nearby. These training exercises also give participants a platform to address concerns about the response plan, such as how to care for vulnerable patients and protect hazardous materials.2,3

What to Do If a Shooting Occurs in a Healthcare Setting

The FBI and Department of Homeland Security (DHS) have developed a three-point plan that every workplace must adhere to in the event of an active shooting. Known as Run, Hide, Fight,this protocol lists the order of actions individuals should follow considering their circumstances. 1,2  

Following this plan, healthcare personnel can quickly determine the most reasonable way to protect their lives and those of nearby patients and visitors.24,25

Run

Following the survivalist mindset, the first line of action should be to evacuate the healthcare facility as quickly as possible if there is an accessible exit path available. To do this safely, it is critical to know all the exits nearby and have a clear escape route in mind. All personal belongings should be left behind to prevent delaying escape, and if there are any mobile patients, efforts should be made to evacuate them as well.1,2However, move quickly and do not wait because it can diminish the chances of survival. If there is resistance from other bystanders, it is necessary to consider self-survival and make the best decision to get out of danger.

If others are heading in a direction where an active shooter may be, efforts should be made to prevent them from going into that area. Any opportunity to evacuate should be taken, and if it is possible to dial 911, call as soon as it is safe to alert authorities of the situation.1,2

Hide

If it is impossible to evacuate the facility, the next course of action is to hide in a place where an active shooter is least likely to discover. Ideally, it should still provide an opportunity to escape if the chance becomes available.

Healthcare personnel can also barricade themselves in inpatient rooms to protect themselves and their patients. To divert attention, close lights, and lock doors. All noise sources, such as TVs and phones, should be silenced, and the door should be blocked by heavy furniture.1,2 Additionally, blinds should be closed, and windows covered to get out of the active shooter’s view. Dial 911 if possible and leave the line open if unable to talk so dispatchers can listen to the situation.1,2

Fight

Fighting the active shooter is a last resort and should only be done when life is in imminent danger. The consequences of a failed attempt are life-threatening, so you should commit fully to actions. Be aggressive, forceful, and vocal to distract and confuse the active shooter. Yell and improvise weapons. Healthcare personnel should focus on disrupting or incapacitating the shooter in any way possible.1,2

Know the Codes at Your Workplace

Every healthcare facility uses color codes to define emergencies.27 These are communicated through an intercom system, thus allowing personnel to respond quickly to various events without creating panic among patients and visitors. It is critical for every person working in a healthcare setting to know the codes of their facility and take active steps to know the protocols for each one. The most prevalent codes used nationwide are given in the table below.27

CodeDescription
BlueCritical medical emergency
RedFire or smoke within the facility
BlackBomb threat
SilverActive shooter
PinkChild or infant abduction
OrangeHazardous material spill incident
Purple (Violet)Violent individual
YellowDisaster
WhiteEvacuation

It is important to note that the US has no standard code system. While certain color codes are universal such as code blue and code red, others are not.27 They may vary from state to state and even from facilities within a city. Therefore, every facility must ensure their on-site employees know the precise coding system so there is no confusion during an emergency.

Get Involved in Your Organization

Healthcare providers and staff participating actively in their workplace’s active shooter plans and responses assist in raising the overall level of preparation. Important steps include actively participating in training activities, by asking questions to improve communication, and practicing drills to mentally and physically prepare for an incident.11 Healthcare staff should be proactive in learning emergency plans, and if there are any areas for improvement, communicate them to managers so that changes can be made to enhance response. The healthcare professional should also respect security protocols by following the rules and regulations, such as wearing a name badge with photo identification, and encourage others to do the same. They should also motivate colleagues to participate in training exercises and keep themselves updated on the response protocols.11

Everyone should be vigilant and assess possible threat situations. If there is any suspicious behavior in the vicinity, pay attention to it. Proactive action can save lives. Additionally, immediately informing superiors of any hostile patients or family members dissatisfied with the treatment or who have made threatening statements. The same should be done when co-workers show signs of aggression or claim unjust treatment in a revenge-like manner.11

Nursing Considerations

In the event of an active shooter, several nursing considerations must be considered. Nurses may find themselves in a situation where self-survival involves leaving their patients.11 This can be particularly difficult to do if those patients are in critical states, such as those in NICUs, dialysis units, and ICUs, or if the event is in the middle of surgery.24,25 Moreover, what if there are injured bystanders or patients? Healthcare providers must decide whether to help the injured or evacuate to save their own life. All the scenarios can lead to complicated ethical and moral dilemmas, where doctors and nurses know they must minimize the loss of life.28 In every scenario, law enforcement agencies advise that every reasonable attempt should be made to provide appropriate care. Still, if it puts more lives at risk, it may become necessary to discontinue care.1,3 Making such a harsh decision is difficult for healthcare providers as they are responsible for their patients and have a duty to care for them.28 Healthcare facilities must address these concerns and discuss specific situations during training so healthcare providers understand how to navigate them should they arise during an active shooting.11

Conclusion

In recent years, active shooter incidents have become more common in workplaces, and as a result, healthcare facilities must be prepared.1 In most cases of active shooters in healthcare, the shooter has a personal grudge against a doctor or employee and is often emotionally unstable. Preparation is the key to minimizing the loss of life and damage, which can have costly repercussions.11 Active training exercises can prepare individuals by teaching a survivalist mindset so they can make logical decisions in an emergency.1 Additionally, regular training programs can help reinforce the response protocols and actions that should be followed. Every facility should have detailed evacuation plans and responses that consider its structure, layout, departments, and patients.1,2

Everyone on-site should be capable of recognizing warning behaviors and signs of aggression so suspects can be neutralized to counter threats. With the right mindset, preparation, and training, healthcare employees will know when to run, hide or fight in the event of an active shooter, effectively protecting themselves and the people around them. 1,2,3

References
  1. Active shooter planning and response in a healthcare setting. (2017, January 24). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active_shooter_planning_and_response_in_a_healthcare_setting.pdf/view
  2. US Department of Homeland Security. (2009). Active Shooter – How to Respond. https://www.dhs.gov/xlibrary/assets/active_shooter_booklet.pdf
  3. Hospitals & Healthcare Facilities Security Awareness for Soft Targets and Crowded Places ACTION GUIDE. (n.d.). https://www.cisa.gov/sites/default/files/publications/19_0515_cisa_action-guide-hospitals-and-healthcare.pdf
  4. Kelen, G. D., Catlett, C. L., Kubit, J. G., & Hsieh, Y.-H. (2012). Hospital-Based Shootings in the United States: 2000 to 2011. Annals of Emergency Medicine, 60(6), 790-798.e1. https://doi.org/10.1016/j.annemergmed.2012.08.012
  5. Wax, J. R., Cartin, A., Craig, W. Y., & Pinette, M. G. (2019). US acute care hospital shootings, 2012-2016: A content analysis study. Work (Reading, Mass.), 64(1), 77–83. https://doi.org/10.3233/WOR-192970
  6. Active Shooter Incidents in the United States in 2018 | Federal Bureau of Investigation. (2018). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2018-041019.pdf/view
  7. Active Shooter Incidents in the United States in 2019. (n.d.). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2019-042820.pdf/view
  8. Active Shooter Incidents in the United States in 2020. (n.d.). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2020-070121.pdf/view
  9. FBI. (2022). Active Shooter Incidents in the United States in 2021. Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2021-052422.pdf/view
  10. Active Shooter Incidents in the United States in 2022. (n.d.). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2022-042623.pdf/view
  11. Schwerin, D. L., & Goldstein, S. (2020). Active Shooter Response. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519067/
  12. Types of Workplace Violence | WPVHC | NIOSH. (2020, February 7). Wwwn.cdc.gov. https://wwwn.cdc.gov/WPVHC/Nurses/Course/Slide/Unit1_5
  13. 1 dead, 4 injured in shooting at Minnesota health clinic. (2021, April 20). AP NEWS. https://apnews.com/article/multiple-people-shot-clinic-minnesota-1385ed48500db468259680cf20469c04
  14. Landry, G., Zimbro, K. S., Morgan, M. K., Maduro, R. S., Snyder, T., & Sweeney, N. L. (2018). The effect of an active shooter response intervention on hospital employees’ response knowledge, perceived program usefulness, and perceived organizational preparedness. Journal of Healthcare Risk Management, 38(1), 9–14. https://doi.org/10.1002/jhrm.21313
  15. 4 killed in shooting at Tulsa medical building, shooter dead. (2022, June 1). AP NEWS. https://apnews.com/article/tulsa-oklahoma-c29a239d1c2ac7f7f0bfdc161b72f6f2
  16. Active Shooter Incidents in the United States in 2016 and 2017 | Federal Bureau of Investigation. (2016). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/active-shooter-incidents-us-2016-2017.pdf/view
  17. Chicago hospital shooting claims 3 lives; gunman also dead. (2021, April 21). AP NEWS. https://apnews.com/article/shootings-us-news-il-state-wire-rahm-emanuel-ap-top-news-dc38f7411db644fba3a6419f21abf69e
  18. Active Shooter Incidents in the United States in 2014 and 2015. (n.d.). Federal Bureau of Investigation. https://www.fbi.gov/file-repository/activeshooterincidentsus_2014-2015.pdf/view
  19. Planned Parenthood shooting suspect insists he’s competent. (2021, April 20). AP NEWS. https://apnews.com/article/ap-top-news-shootings-us-news-state-courts-denver-517b4cd2b04c910b449a6a32527f822d
  20. The cost of surviving gun violence: Who pays? (n.d.). AAMC. https://www.aamc.org/news/cost-surviving-gun-violence-who-pays
  21. Security Violation. (n.d.). Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/news/media/releases/firearm_related_injuries_account_for_28_billion_on_emergency_room_and_inpatient_charges_each_year
  22. Landry, G., Zimbro, K. S., Morgan, M. K., Maduro, R. S., Snyder, T., & Sweeney, N. L. (2018). The effect of an active shooter response intervention on hospital employees’ response knowledge, perceived program usefulness, and perceived organizational preparedness. Journal of Healthcare Risk Management, 38(1), 9–14. https://doi.org/10.1002/jhrm.21313
  23. Simons, A., & Meloy, J. R. (2017). Foundations of Threat Assessment and Management. Handbook of Behavioral Criminology, 627–644. https://doi.org/10.1007/978-3-319-61625-4_36
  24. Reid Meloy, J., Hoffmann, J., Guldimann, A., & James, D. (2011). The Role of Warning Behaviors in Threat Assessment: An Exploration and Suggested Typology. Behavioral Sciences & the Law, 30(3), 256–279. https://doi.org/10.1002/bsl.999
  25. Akiyama, C. (2020). Surviving an Active Shooter Incident in the Intensive Care Unit. Critical Care Nursing Quarterly, 43(1), 3–8. https://doi.org/10.1097/cnq.0000000000000286
  26. Scott‐Herring, M. (2022). Active Shooter Preparedness: Is Your OR Ready? AORN Journal, 115(6), 546–551. https://doi.org/10.1002/aorn.13691
  27. Mapp, A., Goldsack, J., Carandang, L., Buehler, J. W., & Sonnad, S. S. (2015). Emergency codes: a study of hospital attitudes and practices. Journal of Healthcare Protection Management: Publication of the International Association for Hospital Security, 31(2), 36–47. https://pubmed.ncbi.nlm.nih.gov/26411048/
  28. Giwa, A., Milsten, A., Vieira, D., Ogedegbe, C., Kelly, K., & Schwab, A. (2020). Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals’ and Healthcare Institutions’ Moral Obligations During Active Shooter Incidents in Hospitals — A Narrative Review of the Literature. The Journal of Law, Medicine & Ethics, 48(2), 340–351. https://doi.org/10.1177/1073110520935348
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