A Code Silver represents the planned response for a person with a weapon within the hospital.

The Ontario Hospital Association has recommended the addition of Code Silver to separate the response of a person who is actively killing from that of a hostage situation (previously both under Code Purple).  

A review of hospital-related shootings between 2000-2011 in the United States showed a total of 154 shootings with 235 injured or killed victims (1).

  • The most common locations of these shootings were in the:
    • Emergency Department (29%)
    • Parking Lot (23%)
    • Patient Rooms (19%)
  • The most common motives for these shootings were:
    • Grudge (27%)
    • Suicide (21%)
    • Euthanizing an ill relative (15%)
    • Prisoner escape (11%)
  • Of note, event characteristics that distinguished the Emergency Department from other sites included:
    • Younger perpetrator
    • More likely to be in police custody
    • Less likely to have a relationship with the victim(s)

Shootings at Canadian hospitals, while less frequent than our US counterparts, do occur and are becoming more frequent. Examples reported since 2000 are listed below:

Code Silver

For further information on PTSD in the Emergency Department see our previous post.

Run, Hide, Survive

If you see a person with a weapon threatening to harm others on hospital grounds, call the Contact Centre to initiate a Code Silver.

If Code Silver is called, the procedure to remember is “Run, Hide, Survive”

  • Run: Evacuate the area if it is safe
  • Hide:
    • Use a room with a locking door if possible and turn the lights off
    • Barricade the door and silence phones and other sources of noise
    • Hide behind large objects and stay low to the ground
  • Survive:
    • If you are in immediate danger, attempt to disrupt or incapacitate the attacker by:
      • Acting aggressively
      • Yelling
      • Throwing items
      • Improvising weapons

The Ottawa Hospital will be implementing a Code Silver training module with in-situ simulations being rolled out in hospital departments. 

What about patient care during a Code Silver?

Physicians have a duty to care for their patients, but are not required to put themselves in danger. The duty to care is determined by the actions of a “reasonable person” within those circumstances. (2,3)

In assessing physician legal liability and negligence in duty to care in Canada, there are 4 conditions that would need to be met (4):

  • A physician must owe the patient a duty to care
  • A physician must fail to meet the standard of care established by law
  • The patient must suffer an injury or loss
  • Conduct must have been the actual and legal cause of patient’s injury

Hospitals and health care administrators have a further duty to develop safety procedures to maximize the safety of patients, visitors, front-line physicians, and allied healthcare staff. (5,6)


An active shooter scenario has the potential for devastating consequences and is an example of how up-front investment in planning and safety may have significant benefit should an event occur.


  1. Kelen GD et al. Hospital-Based Shootings in the United States: 2000 to 2011. Ann Emerg Med. 2012;60: 790-798.
  2. Kennedy I, Grubb A. Medical law: text with materials. 2nd edition. London: Butterworths; 1994. p. 79.
  3. Singer PA, Benatar SB, Bernstein M, Daar AS, Dickens BM, et al. Ethics and SARS: lessons from Toronto. 
British Medical Journal 2003; 327: 1342–4
  4. Picard EI, Robertson GB. Legal liability of doctors and hospitals in Canada. 3rd edition. Scarborough (ON): Carswell; 1996). p. 174.
  5. Emanuel EJ. The lessons of SARS. Annals of Internal Medicine 2003; 139(7): 589–91, at 591.
  6. Godkin D, Markwell H. The duty to care of healthcare professionals: ethical issues and guidelines for policy development. 2003.