Word spread through an Oregon hospital last month that a visitor was causing trouble in the maternity ward, and nurses were warned the man might try to abduct his partner's newborn.
Hours later, the visitor opened fire, killing a security guard and sending patients, nurses and doctors scrambling for cover.
The shooting at Legacy Good Samaritan Medical Center in Portland was part of a wave of gun violence sweeping through U.S. hospitals and medical centers, which have struggled to adapt to the growing threats.
Such attacks have helped make health care one of the nation's most violent fields. Data shows American health care workers now suffer more nonfatal injuries from workplace violence than workers in any other profession, including law enforcement.
"Health care workers don’t even think about that when they decide they want to be a nurse or a doctor. But as far as actual violence goes, statistically, health care is four or five times more dangerous than any other profession," said Michael D’Angelo, a former police officer who focuses on health care and workplace violence as a security consultant in Florida.
Other industries outpace heath care for overall danger, including deaths.
Similar shootings have played out in hospitals across the country.
Last year, a man killed two workers at a Dallas hospital while there to watch his child’s birth. In May, a man opened fire in a medical center waiting room in Atlanta, killing one woman and wounding four. Late last month, a man shot and wounded a doctor at a health center in Dallas. In June 2022, a gunman killed his surgeon and three other people at a Tulsa, Oklahoma, medical office because he blamed the doctor for his continuing pain after an operation.
It’s not just deadly shootings: Health care workers racked up 73% of all nonfatal workplace violence injuries in 2018, the most recent year for which figures are available, according to the U.S. Bureau of Labor Statistics.
One day before the July 22 shooting in Portland, employees throughout the hospital were warned during meetings to be prepared for a possible "code amber" announcement in case the visitor attempted to kidnap the child, according to a nurse with direct knowledge of the briefing who spoke to The Associated Press. She spoke on condition of anonymity because she feared retaliation at work.
Fifteen minutes before the shooting, someone at the hospital called 911 to report the visitor was threatening staffers, according to a timeline provided by Portland police.
"He kind of fell through the cracks," the nurse said. "I don't know how many chances he received. It kind of got to the point where staff did not know what to do, or what they could or couldn't do with him."
Police arrived at the maternity ward within minutes, but it was too late. Bobby Smallwood, a security guard who had been called in from another Legacy hospital to cover shifts for Good Samaritan's understaffed security team, had been fatally shot. Another hospital employee was wounded by shrapnel. The suspect fled and was later killed by police in a nearby community.
The hospital declined to respond to the nurse’s comments because the case is still under investigation.
"Events like these are unpredictable, but our team exhibited professionalism and a great deal of courage in the face of extraordinarily challenging circumstances that day," Legacy Health said in a statement to the AP.
Legacy Health in Portland plans to install additional metal detectors, require bag searches at every hospital and send patients and visitors to controlled entrances. More security officers will be provided with stun guns, the hospital said, and bullet-slowing film is being applied to some interior glass and at main entrances.
Around 40 states have passed laws creating or increasing penalties for violence against health care workers, according to the American Nurses Association. Hospitals have armed security officers with batons, stun guns or handguns, while some states, including Indiana, Ohio and Georgia, allow hospitals to create their own police forces.
Critics say private hospital police can exacerbate the health care and policing inequities already experienced by Black people. They also say private police forces often don't have to disclose information such as how often they use force or whether they disproportionately detain members of minority groups.
Security teams cannot address all of the factors leading to violence because many of them are caused by a dysfunctional health care system, said Deborah Burger, a registered nurse and the president of National Nurses United.
Patients and families are often bounced between emergency rooms and home, and are frustrated over high costs, limited treatment options or long wait times, Burger said.
"Hospitals don’t really have a complaints department, so the only real target they have is the nurse or staff that are standing right in front of them," she said.
Understaffing forces nurses to care for more patients and affords them less time to assess each one for behavior problems. Efforts to de-escalate aggression aren't as effective if nurses haven't had time to bond with patients, Burger said.
Growing nurse-to-patient ratios are an "absolutely catastrophic formula for workplace violence increasing," D'Angelo said. "Now you don’t even have the good old buddy system of two co-workers keeping an eye out for each other."
Some hospital administrators encourage staff to placate aggressive visitors and patients because they are worried about getting bad reviews, Burger said. That’s because the Affordable Care Act tied a portion of federal reimbursement rates to consumer satisfaction surveys and low satisfaction means a hit to the financial bottom line.
"The results of those surveys should never take priority over staff safety," D’Angelo said.
Eric Sean Clay, the president-elect of the International Association for Healthcare Security & Safety and vice president of security at Memorial Hermann Health in Houston, said the workplace violence rates attributed to health care facilities are "grossly underreported."
"I think that a lot of it comes down to caregivers are just very tolerant, and they come to look at it as just part of the job," he said. "If they’re not injured, sometimes they don’t want to report it, and sometimes they don’t think there will be any change."
Clay’s hospital uses armed and unarmed security officers, though he hopes to have them all armed eventually.
"We actually have our own firing range that we use," Clay said. None of his security officers have drawn their weapons on the job in recent years, but he wants them to be ready because of the rise in gun violence.
Clay and Memorial Hermann Health declined to answer questions about whether an armed security force could negatively affect access to health care or existing inequities.
The nurse at the Portland hospital said the shooting left her colleagues terrified and unusually solemn. She is worried Legacy Health's promises of increased safety will be temporary because of the cost of finding, training and retaining security officers.
Some of her co-workers have resigned because they don't want to face another "code silver," the alert issued when someone at the hospital has a weapon.
"You know, we always say these patients and their families are so vulnerable, because they’re having the worst day of their life here," the nurse said, and that makes many staffers reluctant to demand better behavior.
"We have to stop that narrative," she said. "Being vulnerable is bleeding out from a bullet wound in your chest. Being vulnerable is having to barricade yourself and your patients in a room because of a code silver.’"