Hospital drill goes wrong; gunman traumatizes staff
A hospital's attempt to prepare for armed intruders took a bad turn when a drill simulating a man with a gun taking over a patient care unit was too real for some staff. Many did not know that it was a drill and were severely traumatized. Plus, the clinicians were kept from their critically ill patients until the drill was cancelled.
The incident happened May 24 at St. Rose Dominican Hospital in Henderson, NV. According to a report from the state's Bureau of Health Care Quality and Compliance, staff were not notified of the drill, not even administrators. "None of the employees developed or submitted a written scenario of the drill to administrators for approval prior to implementation," the report says. "The armed terrorist drill was not announced as a drill and staff thought there was a real armed hostage crisis occurring."
A man walked into the intensive care unit (ICU) with a gun and held two nurses, two doctors, a respiratory therapist, the director of the ICU, the charge nurse and a house supervisor in a break room for about 15 to 20 minutes, the report says. Several staff members and nurses were "emotionally traumatized by the armed hostage drill," and some were "crying and visibly upset" while they were held in the break room, the report says.
One employee reported that she was walking to the break room with a breakfast tray when she saw a man pointing a gun at her. She told investigators she "feared for her life." After a few minutes of being held in the break room, the man told the employees he was an off-duty police officer and that he was conducting a drill for the hospital. They stayed in the break room for about another 10 minutes before the drill was cancelled.
The Nevada Health Division has issued a statement saying the hospital may be fined for the incident, because the critically ill patients were unattended for the duration of the drill. The drill fine probably would be only about $800, it said.
How it happened
The drill was well-intended, but it turned into a disaster, says the hospital's chief operations officer, Teressa Conley, RN, MBA, MSN, EA. Conley was in her office when the incident happened, and she was not informed beforehand. She says the drill was planned by a three-person environment-of-care (EOC) committee that had conducted drills of various types, including what the hospital calls "Code Silver" drills to simulate a person with a gun in the facility. The EOC committee was well respected and had received accolades for its previous work, Conley says.
Code Silver drills were considered necessary after an incident one year ago in which a person came to the emergency department, drew a gun on patients and staff, and was shot dead in the ED by local police, Conley explains. The hospital developed the Code Silver protocol, which begins with sounding the Code Silver over the paging system and stating the location. That signals to all staff that there is an incident with a weapon involved, and that they should stay away from the area.
After the shooting in the ED, there were more incidents involving firearms there. Staff managed to take possession of the guns before anyone was hurt, but hospital leaders felt that the risk of violence was growing. Conley notes that The Joint Commission said the same thing recently with its warning about increased violence in health care facilities.
"It's getting to be the nature of [the] environment," she says. "We just have to do what we can to protect our staff. So, that was the background into this."
Code Silver drills had been held previously in the ED without difficulty, Conley says. This time, the EOC committee chose to have the drill in a different unit the ICU and most critically, decided not to inform hardly anyone that it was a drill as required by hospital policy.
"They did this based on feedback, debriefing sessions, from other drills. The feedback was that the codes were not very realistic because everyone knew it was a drill and that fear, that emergency reaction, was missing," Conley says. "So, they didn't follow the appropriate policies and procedures regarding the communications channels. In fact, that was intentional, because they wanted to create a level of secrecy, so they could have the element of surprise and bring that realistic nature to it."
Drill was unexpected
On the morning of the drill, Conley was working in her office when at about 10 a.m., she heard an overhead page for a Code Grey in the ICU, the hospital's code for an altercation with a patient or family member that does not involve a weapon. Such calls are not uncommon, and security responds to the scene. Conley took notice but didn't think much of the incident.
Ten minutes later she heard a page for a Code Silver in the ICU. Thinking the first incident had escalated to a gun situation, Conley called the nurse supervisor for that unit one of the few people who had been alerted to the drill. The EOC committee had instructed her to only say that something was happening and she couldn't talk. She said that to Conley and hung up the phone, further stoking fears of a serious situation.
"I was thinking 'Oh my God, this is the real deal,'" she said.
Conley rushed to the ICU and at the entrance she met two of the EOC committee members, the hospital's director of security, an officer from the Henderson Police Department, and several other people. The EOC committee members told her it was only a drill, but Conley said, "You know, this has not been paged as a drill. People think this is a real situation." She then asked when the committee was going to call off the drill.
The group coordinating the drill assured Conley that the staff in the ICU knew it was a drill, so she did not push further.
The group did not want to call off the drill yet, saying it was effective and that realism was the goal. Not knowing what was going on on the other side of the doors to the ICU, Conley waited with the group until the EOC committee decided to call off the drill about 15 minutes after it began.
After the drill, Conley realized that the scene on the other side of the doors was worse than she thought. Staff were traumatized and angry, and there was concern that patients had been neglected during the incident. The hospital launched a full investigation and did not like the results.
Staff left traumatized
Conley determined that the committee had worked with the director of security to plan the scenario, contacting the local police department to get the cooperation of an off-duty officer who would play the gunman. He was instructed to enter the ICU with a gun, round up all the employees, and herd them into a break room. The committee notified only a handful of people in the hospital, including the ICU's nursing supervisor, but instructed her to play along and not to divulge that it was a drill.
The fake gunman said afterward that, once he had rounded up the employees, he informed the employees quickly that it was only a drill. Some of the staff reported that they had heard him say that, while others said they did not. Even the director of the department thought it was real.
"A good number of the individuals taken into that back room did not know it was a drill," Conley says. "They thought it was the real deal. And in some ways that was the plan. That was really the most egregious part of it. Some of the staff have been traumatized by it."
The first concern was for the traumatized staff, Conley says. The hospital offered counseling sessions with the hospital chaplains and offered extended employee assistance program (EAP) services to those staff. There is no indication yet whether the traumatized employees might sue the hospital, she says.
"Our goal was to do anything we could to support the staff," she says. "At the same time, we were proceeding with our investigation. As a hospital leader, I want to make sure this never, ever happens again."
The hospital has learned many lessons from the experience, Conley says.
Conley says she is certain the state will fine the hospital for the incident, and she doesn't dispute that a fine is appropriate. While she was greatly relieved to find out that no patients or family members were harmed during the fake drill, she acknowledges that the potential was there.
The members of the EOC committee and the director of security were placed on involuntary administrative leave until the investigation was completed. When Conley and other administrators were clear on how the incident unfolded, the director of security resigned and the committee members were relieved of their committee posts.
"They never dreamed that it would go as wrong as it did, but clearly they had to be removed from those positions of leadership," Conley says. "Once an egregious decision like this is made, the organization can no longer trust them in that role again."
Source
Teressa Conley, RN, MBA, MSN, EA, Chief Operations Officer, St. Rose Dominican Hospital, Henderson, NV. Telephone: (702) 616-5578. E-mail: [email protected].
A hospital's attempt to prepare for armed intruders took a bad turn when a drill simulating a man with a gun taking over a patient care unit was too real for some staff. Many did not know that it was a drill and were severely traumatized. Plus, the clinicians were kept from their critically ill patients until the drill was cancelled.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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