When It Comes to Hospital Shootings, Emergency Color Codes Don’t Work

Brigham and Women's was prepared for the worst. Other hospitals should take note.

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It is hard to think that anything went right at Brigham and Women’s Hospital (BWH) on the morning of January 20, when Stephen Pasceri murdered cardiac surgeon Michael Davidson and then turned the gun on himself. Yet in the midst of the chaos, a lot of things did go right: Police were on the scene within seconds; all 5 million square feet of the hospital were cleared within 16 minutes; and the violence did not spill beyond the exam room.

Perhaps one of the most important lessons of this tragedy is contained in a 39-word script that was read aloud over the hospital’s PA system moments after the first shots rang out: “A life-threatening situation now exists at Watkins Clinic B—Shapiro 2. All persons should immediately move away from that location if it is safe to do so. If it is not safe to move away, shelter in place immediately.”

Had the horror unfolded at another hospital, there’s a good chance that bystanders would have been met with a vague color-coded emergency warning—Code Silver or Code Green, for instance.

Color codes are part of hospital culture. Spend enough time at a health care facility and you’re bound to hear a Code Blue or Code Pink or Code Amber. These seemingly benign announcements help staff respond to emergencies without inciting alarm. But this system fails when the emergency at hand threatens visitors, patients, and other individuals who aren’t versed in the spectrum of codes.

Given the rise of hospital shootings—they are now a monthly occurrence in the U.S.—should color codes for such emergencies be replaced with straightforward announcements?

“It really does not make sense to call a code,” says Robert Chicarello, director of security at BWH. Chicarello says the issue first came to his attention after the 2007 Virginia Tech shooting, which claimed more than 30 lives. As the years went on and massacres piled up across the country, BWH took a close look at its plans for responding to an active-shooter situation. From the outset, Chicarello and his team were keenly aware that approximately 26,000 people walk through the hospital’s doors every day, thousands of whom have no training in hospital codes.

Under the old plan, a shooting at BWH would have been met with a Code Gray. Through a series of roundtables and trainings, a team from the hospital decided in late 2013 to replace the code with a scripted announcement. “It needs to be plain English so untrained visitors, patients, anybody who is in the building, can hear it and know what’s happening. I would preach that to anyone who would listen. It doesn’t have to be what we used, but it needs to be plain English. There’s no downside,” Chicarello says.

There are, however, numerous challenges. Emergency codes aren’t standardized. The Joint Commission, which accredits and certifies more than 20,000 health care organizations across the U.S., “does not have specific hospital standards addressing emergency color codes,” according to an email from spokeswoman Katie Looze Bronk. The Massachusetts Hospital Association, a group that represents more than 100 members, also does not have specific recommendations pertaining to emergency codes.

But standardization may not be the key to clarity. Different hospitals with different departments have different needs. Instead, what’s needed is specificity and candor. Take for example the Hospital Association of Southern California, which standardized color codes in 2000, according to its website. Under that system, last updated in 2014, Code Gray indicates a “combative person” while Code Silver indicates a “person with a weapon and/or active shooter and/or hostage situation.” Both codes represent situations that could potentially harm bystanders, yet neither actually alert lay folk as to what’s happening.

Given the Brigham community’s longstanding reputation for innovation, it’s no surprise they were prepared for the worst. Today, they continue to prepare by dissecting and analyzing the events of January 20 in hopes of gleaning lessons that can safeguard hospitals across the country from similar shootings.

Still, while the scripted announcement proved effective that deadly winter morning, there’s room for improvement, says Eric Goralnick, medical director of emergency preparedness at BWH. “Our plain language probably isn’t plain enough,” he says, noting that in follow-up interviews after the shooting, several people raised concern with what the term “shelter in place” means.

In the wake of Davidson’s murder, Partners HealthCare, the parent organization of BWH, Mass General, and McLean Hospital, among others, has implemented the scripted shooter warning across all of its facilities. Goralnick would like to see other hospitals follow suit.

“There’s been a longstanding tradition of using these emergency color codes in hospitals,” Goralnick says. “But from the feedback we have gotten from staff, patients, and families, clarity and transparency are critical.”