Threat Assessment Strategies to Mitigate Violence in Healthcare


It is clear that workplace violence, specifically in healthcare, is an issue that governments and regulatory bodies are struggling to address.  Even with guidance, recommendations and legislation, much of the onus falls on the individual organization to create a strategy to manage workplace violence. One such strategy is to develop a thorough TA team and process.

There are significant differences between risk assessment (RA) and TA, although the terms are sometimes used interchangeably.  According to Randazzo and Cameron, “violence risk assessment – also referred to as clinical assessment of dangerousness – is a process used by trained professionals to evaluate the likelihood that a particular person will engage in general violence. Risk assessment is based upon empirical research on the prevalence of general/impulsive violence in particular populations, as well as on individual factors that are statistically correlated with violent behaviors.”  Beginning with a base rate and then adjusting based on associated risk factors, the assessor arrives at an estimate of risk, typically expressed as low, medium or high.[38] 

TA, on the other hand, is a behavioral-based, deductive process.  Randazzo and Cameron write that it is typically conducted by a team and comprised of four components: learning of a person who may pose a threat, investigating that person, evaluating whether the person poses a threat to others and developing and implementing a plan to reduce the threat. 

The concept of TA was developed by the U.S. Secret Service as a means to evaluate potential threats against the President.  The process was based on the Exceptional Case Study Project (ECSP), which analyzed the characteristics, actions and behaviors of people who had carried out attacks on public figures.  The analysis of these individuals showed that risk factors for general violence, such as a history of violence, were often not present; however, other indicators such as plans for harm and communications to others indicating a desire to attack were.[39]  The primary premise of TA is that targeted violence is the result of an understandable and often discernible process of thinking and behavior. Acts of targeted violence are rarely impulsive or spontaneous; therefore, there are opportunities to recognize, investigate and mitigate the threat before violent action occurs.[40]

The information gleaned from the ECSP allowed the Secret Service to develop the TA process and produce a guide to behavioral-based TA for targeted attacks in the late 1990’s.  Following its publication, there was enormous demand from law enforcement agencies to apply the guidelines. This led to the development of the National Threat Assessment Center.[41]  Businesses and private entities then began to adapt the model to their environments. 

TA continued to develop following the Columbine shooting in the United States in 1999 and a major school shooting in Taber, Alberta, Canada the subsequent week.  The Secret Service collaborated with the U.S. Department of Education on the Safe School Initiative (SSI), creating further research and bringing an amended TA model to the K-12 school system.[42]  Following the Virginia Tech shooting in 2007, TA was brought into colleges

and other post-secondary education settings.  The state of Virginia went as far as to enact a law requiring all colleges and universities to have TA teams. 

There are several key principles in TA that were derived from the ECSP and SSI.  These include:

  • Targeted attacks are rarely sudden, impulsive acts
  • Prior to the attacks, others often knew about the attacker’s idea/plan
  • Most attackers did not threaten their targets directly prior to the attack
  • There is no accurate or useful “profile” of a targeted shooter
  • Most attackers had difficulty coping with significant losses or failures
  • Most attackers had behaved in a way that concerned others in their lives
  • Prior to the attacks, many attackers felt bullied, persecuted or injured
  • Most attackers had access to and had used weapons prior to the attack[43]


There is an abundance of research and a variety of tools for conducting and applying violence RA in healthcare, but that is not the case for TA.  In fact, no research was identified specifically applying TA to the healthcare field.  In general, there is minimal research on using TA in private industry aside from education, and the research that has been conducted is difficult to find.   Mitchell and Palk conducted a comprehensive literature review on TA published in 2016 finding that only about half of the 66 relevant articles were found via literature review.  The other half were found by analyzing recommended readings from the websites of chapters of the Association of Threat Assessment Professionals.[44] 

Even without specific research, TA is a recommended tool for healthcare by the Office of Quality and Patient Safety at The Joint Commission,[45] but the difficulty in accessing information and the lack of healthcare specific research leads to limited application.  While TA is not applicable to unintended or reactive violence often seen in the Emergency Department, there are several other situations in healthcare where TA may prove to be a valuable tool as part of a comprehensive violence management program.  These situations include stated or implied threats from patients or families, patients who have been violent during a previous visit or admission, intimate partner situations and terminated/disgruntled employees.  The significant results that have been achieved in the field of education, which uses the model regularly, warrant additional investigation for application to healthcare. 

The following list includes recent examples of targeted violence incidents in healthcare.  As this article continues to outline the TA process, consider how it may have assisted in the management and/or mitigation of the incidents. It is not known if TA was used in any of these cases, which were gleaned from a variety of news sources.   

  • On June 30, 2017, a disgruntled physician concealing a rifle beneath his lab coat walked into Bronx-Lebanon Hospital Center in Bronx, New York. He killed a physician and wounded six other people before setting himself on fire and shooting himself.  The gunman had worked at the hospital for about six months before quitting after being accused of sexual harassment.  Years earlier, he was arrested and charged with sexual abuse after assaulting a woman in Manhattan.[46]
  • On March 15, 2018, an employee of UAB Highlands, an affiliate of the University of Alabama at Birmingham, shot and killed a nursing supervisor, wounded a contractor and then committed suicide. The employee was described as “disgruntled” and police determined an “employee relations issue” led to the incident.[47]
  • On July 20, 2018, a prominent surgeon was killed while riding his bike to work at Texas Medical Center in Houston, Texas. The gunman appears to have had a grudge over the death of his mother during surgery by the physician 20 years prior.[48]
  • On October 15, 2018 an employee of Kadlec Regional Medical Center in Richland, Washington, walked into the facility with a gun. He was verbally suicidal and threatened to kill multiple people before fleeing the area.  He was later peacefully arrested.[49]
  • On November 19, 2018, a shooting took place at the Mercy Hospital and Medical Center in Chicago, Illinois. An attending physician at the hospital, a police officer, a pharmacy resident, and the perpetrator were killed. The incident began in the parking lot of the hospital when the gunman, who was the ex-fiancé of the physician, demanded she return an engagement ring.  The doctor was killed in the parking lot, then the gunman continued into the hospital and shot others.  It was later determined that five years prior to the incident, the gunman had threatened a shooting at the Chicago Fire Academy after he had been terminated as a trainee for aggressive and improper conduct toward women.  In 2014, the gunman’s wife at the time filed a petition for an order of protection against him, alleging threats and harassment.[50]
  • In April, 2019, a 54-year-old patient in the inpatient behavioral health unit at Baton Rouge General Medical Center began attacking a nurse.  A second nurse intervened to assist and the patient attacked her as well, causing her to injure her right leg and strike her head on a desk.  The injured nurse was treated and
  • released from the ER but died the following week from blood clots resulting from the attack. The patient has been charged with manslaughter.[51]
  • On June 19, 2019, a recently terminated employee made threats to open fire at Methodist Specialty & Transplant Hospital in San Antonio, Texas. He told a co-worker he was going to “shoot everyone inside for firing him.”   On June 20, someone threw a liquor bottle through the entrance window of the hospital and a man matching the description of the terminated employee was seen in the area.  The man was arrested and charged with making a terroristic threat.[52]


[38] Marisa Randazzo & J. Kevin Cameron, From Presidential Protection to Campus Security: A Brief History of Threat Assessment in North American Schools and Colleges, (Journal of College Student Psychotherapy, 2012), 279.

[39] Ibid., 280-281.

[40] Bryan Vossekuil, et. al., Threat Assessment: Assessing the Risk of Targeted Violence, (Journal of Threat Assessment and Management, 2015), 246-247.


[42] Randazzo & Cameron, From Presidential Protection to Campus Security, 282.

[43] Vossekuil et. al., Threat Assessment: Assessing the Risk of Targeted Violence, 249.

[44] M. Mitchell & G. Palk, Traversing the Space between Threats and Violence: A Review of Threat Assessment Guidelines, (Psychiatry, Psychology and Law, 2016), 866.

[45] Ron Wyatt, et. al., Workplace Violence in Health Care: A Critical Issue with a Promising Solution, (Journal of the American Medical Association, 2016), 1038.

[46] Sarah Maslin Nir, Doctor Opens Fire at Bronx Hospital, Killing a Doctor and Wounding 6, (New York Times, 2017) [online].

[47] Alabama hospital gunman identified as disgruntled employee, authorities say, (CBS, 2018) [online].

[48] Doug Stanglin, Suspect in murder of former George H.W. Bush’s doctor was patient’s son who held grudge over mother’s death, police say, (USA Today, 2018) [online].

[49] Elaine Sheriff, Man who threatened to shoot Kadlec employees works at hospital, (KEPR TV, 2018) [online].


[52] Steven Porter, Patient Faces Arrest for Attack That Killed Louisiana Nurse, (Health Leaders Media, 2017) [online].

[52] Maritza Salazar, Man accused of threatening to open fire at San Antonio hospital after he was fired, (News4SA, 2019) [online].