Code Silver: Sanctuary Under Fire

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:

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)

Conclusion

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.