Combative Individual with Weapon

Introduction

Date of Last Review 12/20/2011
SME: Safety Compliance Coordinator

POLICY:

In the event that hospital staff is involved in a situation in which an intruder with a gun has entered the hospital, immediately notify UT Police by dialing 911.

UT Police will take charge of the investigation and resolution of the situation.

PROCEDURE:

Staff Role and Responsibilities

Staff encountering an individual with a gun shall:

• Physical description of the individual with the gun
• Location of the individual
• Weapon/s the individual has
• Number of people (patients, visitors, staff) involved
• Call the Switchboard Operator at 741-2633. Tell the Switchboard Operator to announce a "CODE SILVER" and the location.
• You should then seek a safe area.

The Switchboard Operator will announce on the overhead paging system, "CODE SILVER" and the location taking place three (3) times.

The Switchboard Operator will notify Security at the front entrance.

The Operator will notify the following staff:

• The Chief Administrator or administrator on-call or the Nursing Supervisor
• The department/unit involved
• The Director of Facilities at 741-8690 or after-hours the Facilities Department at 741-8695

Hospital staff will NOT go to the paged unit/area the intruder was identified.

• Staff should ensure a barrier can be created between patients/visitors/staff and the intruder, i.e., locking doors, placing furniture against the door
• Staff will direct patients and visitors to a safe location such as the patient sleeping rooms
• Turn off the lights, cell phones, and pagers
• Facilities Management will control the elevators and prevent access
• Department Directors will proceed to Incident Command Center (3D09) with caution. Floor plans will be provided.
• The Switchboard Operator will provide floor plans to UT Police when they arrive. Floor plans are kept in the Switchboard Operator's room (1A59)
• Remain in the safe area until a "Code Silver All Clear" announced is made on the overhead paging system

Basic ground rules will guide the behavior of staff on the department/unit that recognizes that an incident is taking place:

• Remain calm and observant
• Attempt to leave without being observed
• Use stairways, not elevators. Attempt to move ambulatory patients, if possible. Again, if possible, do so without being noticed.
• Immediately report to Incident Command Center (3D09) and provide the Incident Commander as many details as possible such as the physical description, clothing, speech, height, accents, how many people, behavior, weapons, and any other detail related to the incident.

UT Police Responsibilities:

• When the UT Police Dispatcher on duty receives the initial notification of a "CODE SILVER", dispatch will document the sequence of events including date, time and name of person providing the information, and all post assignements. UT Police will then take command of the situation keeping the Incident Command Center as information received.
• UT Police will continuously monitor all closed circuit television at the front entrance and provide possible warning to UT Police responding to "CODE SILVER".
• UT Police will work with other law enforcement to monitor all exits.
• UT Police will provide master keys to law enforcement kept in the Switchboard Operator's room.
• UT Police will work with staff to direct patients, visitors, and staff to a safe location, as applicable.

Related Standards

The Joint Commission: Emergency Management

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