What to Do in an Active Shooter Situation

Does your workplace have a plan in place for how to handle an active shooter? Would you know how to react to protect yourself and your patients or clients?

Mass shooting incidents have increased in recent years, prompting individuals and organizations—including hospitals and other healthcare facilities—to consider active shooter response plans. Do you know what to do if there's an active shooter where you work?  

A Rare but Deadly Problem  


Hospital Shootings by the Numbers 


Between 2000 and 2011, 154 hospital-related shootings occurred. 91 occurred inside the hospital, and 63 occurred outside on hospital grounds.1 


  • The shooter themselves are the victim in 45% of cases. 
  • Nurses account for 5% of victims, while physicians account for 3%. 
  • 91% of perpetrators were men. 
  • Motivations include:  
    • Grudge 
    • Suicide 
    • Euthanasia of an ill relative 
    • Prisoner escape 

According to the U.S. Department of Homeland Security, active shooters typically have no pattern or method for selecting their victims.  

The Risk to Healthcare Facilities 

Most healthcare facilities are open to the public, sometimes at unusual hours, making it relatively easy for a shooter to gain access. Reductions in community psychiatric resources also increase the numbers of patients with serious mental illness, which may result in more dangerous situation.  

Shooting events are unpredictable and difficult to prevent, but safety precautions should be put into place, and an active shooter response plan should be implemented so that all staff are prepared to react quickly to preserve their own safety and the safety of patients.   

Depending on the set up of your facility, you may want to consider extra security precautions, such as conducting bag checks, increasing security staff, and installing metal detectors.  

Be Prepared  

Know What to Look For 

An active shooter could be an employee, a patient or client, a physician, or someone else. Be alert for people acting suspiciously, such as appearing nervous when you ask simple questions, or exhibiting signs of potentially violent behavior, such as:  

  • Depression or withdrawal 
  • Repeated violations of your facility’s policies 
  • Explosive outbursts of anger 
  • Unexplained increase in absenteeism 
  • Decrease in attention to appearance and hygiene 
  • Talk of severe financial problems or previous incidents of violence  

Report any concerns to your manager and, in the case of patients or clients, document your objective observations in the medical record.  

It’s important to know that in January 2013, the Department of Health & Human Services released a letter to healthcare providers saying that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule “does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people.” The letter recommends that clinicians be aware of state laws related to disclosure of patient information to prevent or lessen the risk of harm.  

Understand the Risks in Your Area 

Facilities should review crime statistics for their area and involve employees to identify areas that need more security. The Emergency Nurses Association developed an algorithm for mitigating violence—and although it is hospital-focused, many of its principles are helpful in clinic settings as well. Visit www.ena.org for more information.  

Ask for Support 

Don’t be afraid to ask for security presence if you suspect a patient or client has the potential for violence. Your facility may want to consider closed circuit monitoring and should ensure sufficient lighting exists. Be sure your facility has a zero tolerance policy, which has been found to reduce the numbers of violent incidents.  

Prepare and Practice 

You should participate in training exercises, which are the most effective means for preparing you. In the training, you will likely learn how to recognize the sound of gunshots, how to react, and how to adopt a survival mindset. Ideally, security in your clinic and local law enforcement will participate in the training. Participation should be documented in the employee’s education record.  

Establishing a Plan of Action 

An active shooting is typically over within 10 to 15 minutes, so advanced preparation on how to react is essential. Ensure that your facility has an emergency plan that covers active shooters and includes areas of responsibilities, emergency phone numbers, and response plans. If it doesn’t, volunteer to help create one. 

It’s best to have a code specific to this situation, such as “Code Silver” or “Code Gray.” This prevents people rushing to the scene to “help” and instead being put in harm’s way because an insufficiently specific code was used.  

Because communication can be particularly challenging in these situations, it’s important to set up a command center and to establish clear lines of communication, including how to notify people when the crisis is over. In some cases, social media may be appropriate for updates to the public.  

The U.S. Department of Homeland Security offers these suggestions for responding when an active shooter is in your area:  


Exit if there is an accessible escape route. Leave your belongings behind and try to help others escape. Keep your hands visible so law enforcement can see that you are unarmed.  


If you can’t get out, find a place to hide. Block entry to your hiding place if possible, for example, by pushing furniture against the door. Silence your cell phone or pager, and turn off any other sources of noise, such as a radio or television.  

Take action.  

As a last resort, and only if your life is in imminent danger, try to incapacitate the shooter. Find a makeshift weapon and act aggressively: yell and throw items. Try to remain calm, particularly if you are with patients or clients at the time.  

When you contact 9-1-1, give the location of the shooter, the number of shooters, a physical description, number or type of weapons, and number of potential victims. When law enforcement or security arrives, follow their orders, knowing that they may shout commands and use pepper spray or tear gas. If you are not directly in the area of the shooting,  take actions such as ensuring that emergency vehicles are diverted from the facility, securing elevators to limit the shooter’s access to other floors, and monitoring and reassuring patients and others who may be aware of what is happening.  

Tap into Resources  

Several resources are available to help you learn more about responding to an active shooter:  

Hospital Code Silver Activation: Active Shooter Planning Checklist.  

Developed by the California Hospital Association, with input from agencies such as FEMA, U.S. Department of Homeland Security, and the International Association for Healthcare Security and Safety, this checklist covers several components including: mitigation, preparedness, response and recovery. Although designed for hospitals, it can be useful for other healthcare facilities. Download a copy at www.calhospitalprepare.org/post/hospital-code-silver-activation-active-shooter-planning-checklist

Videos and webinars.  

Several training videos and a webinar are located at www.calhospitalprepare.org/active-shooter. 

Active Shooter: What You Can Do.  

This free interactive web-based course from FEMA provides guidance for individuals. Visit www.fema.org for more information. 

U.S. Department of Homeland Security.  

This department published Active Shooter: How to Respond booklet as well as a pocket card with key information. Both are available in English and Spanish. You can access these, as well as a webinar and other resources, at www.dhs.gov/active-shooter-preparedness

Emergency Nurses Association Workplace Violence Toolkit.  

Although not specific to an active shooter, this includes relevant information such as how to develop an action plan. Visit www.ena.org for more information.  



Nurses—and our patients—could easily be in the line of fire should an active shooter enter the hospital. By being prepared and alert, you can help mitigate a tragic situation.” 

   - Cynthia Saver, MS, RN, President, CLS Development, Columbia, Maryland 

Active shooter situations are terrifying, dangerous, and unpredictable. But as members of the “front line”, nurses have an opportunity to make sure they’re ready to react to a dangerous situation. Be proactive, help your organization implement and practice a response plan, stay alert, and be prepared.  

References & Resources 

1 Kelen GD, Catlett CL, Kubit JG, Hsieh Y. Hospital-based shootings in the United States: 2000 to 2011. Ann Emerg Med. 2012;60:790-798. https://www.hasc.org/sites/main/files/03-hos1_0.pdf 

California Hospital Association. Hospital code silver activation: Active shooter planning checklist. 2012. Available for download

Department of Health & Human Services. Message to Our Nation’s Health Care Providers. January 15, 2013. 

Emergency Nurses Association. Violence mitigation: Concept to implementation algorithm.  

Howell WLJ. Violence in hospitals. Hospitals & Health Networks. 

U.S. Department of Homeland Security. Active Shooter: How to Respond. 2008. 

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

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