December 21, 2021By Lance Baily

Code Silver: Healthcare Simulation Training Exercise For Mass-Shooting Incidents

Today, healthcare simulation education encompasses many types of patient safety preparedness training. Included in this training, medical facilities in many provinces or states in North America, such as hospitals, are now teaching their employees how to respond to a person with a weapon such as an active shooter. Referred to as “Code Silver,” this hospital response was explained in the Advances in Simulation research article titled “The Code Silver Exercise: a low-cost simulation alternative to prepare hospitals for an active shooter event.”

According to the article “Hospital-based shootings in the United States: 2000 to 2011,” a study between 2000 and 2011 showed 154 hospital-based shootings in the USA. This study also identified that the emergency department (ED) and hospital parking lots were the most vulnerable locations for these incidents. This knowledge helps exemplify why the implementation of a CSE is important throughout training across hospitals as these precautions help staff to create a mental schema prior to an active shooter event. These experiences therefore indirectly improve the chances of survivability in the event of a real active shooter situation.

Ultimately, the rise in gun-related violence and mass casualty shooting events has necessitated the development of this type of preparedness strategy, and the CSE acts as a practical and sustainable training tool. Plus, CSE is a reproducible clinical simulation alternative, designed to operationalize a Code Silver policy at a large healthcare institution in a sustainable way. Within the article, authors Julie J. Kim, Daniel Howes, Chantal Forristal, and Andrew Willmore share how active shooter responses across hospitals are quickly shifting from a theoretical safety measure to realistic scenarios that must be prepared for.

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Conceptualized and trialed for feasibility and efficacy, a Code Silver Exercise (CSE) involves an independent mental practice experience with written responses to scenarios and questions, followed by a facilitated debrief with all participants. The simplicity and flexibility of the tool by utilization of mental practice make CSE sustainable for larger institutions to implement without significant budget allocation or affecting patient care in clinical areas. CSE objectives include to:

  • Review the steps to activate and respond to a Code Silver in the hospital
  • Have participants mentally practice various scenarios presented within an active shooter scenario
  • Debrief and discuss logistical and ethical considerations with colleagues in a facilitated debrief by content experts.

The authors shared that the CSE was piloted as a quality improvement and emergency preparedness initiative in three different settings. These settings included in situ within a hospital Emergency Department or Intensive Care Unit, offsite in a large conference room workshop, and online via a virtual platform. They also took place in four different cities in Canada and included three academic teaching hospitals.

Participants of the in situ and virtual CSE completed pre-and post-simulation surveys designed to exhibit an improved understanding of Code Silver protocols following participation. Total participation included n=9 for the in-situ CSE, n=24 for the workshop CSE, and n=25 for the virtual CSE. For the voluntary debrief portion of the virtual CSE, n=11 physicians participated in the facilitated debrief 1 week later via Zoom videoconference.

Further, the ability to be administered in multiple settings in-person (in situ or offsite), and virtually, makes this training model versatile and easily accessible for learners. The CSE enables participants to mentally rehearse practical responses to an active shooter in their unique work environments. They can discuss ethical and medical-legal implications of their responses during a facilitated debrief with fellow healthcare providers as well.

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Ultimately, while the CSE exercise showed promise, the scope of this pilot was unable to show lasting impact and long-term retention of knowledge using CSE. The authors found that they could not definitively demonstrate superiority over computer-based learning modules. Yet, pilot studies in medical education comparing immersive learning techniques such as healthcare simulation compared to didactic or pre-recorded computer teaching have highlighted either no difference or greater knowledge retention and engagement with immersive learning.

An active shooter event is an example where the physical, psychological, and legal consequences for the split-second decisions of healthcare providers require individual reflection and forethought prior to a real event. Whereas an electronic learning module or video simply delivers information to a broad audience, the CSE requires one to mentally practice and develop a construct for how to act and react in an active shooter situation. Then, a conclusion exercise allows staff to reflect, plan an escape route, locate safe hiding places, and consider tools for self-defense.

Read the Full Advances in Simulation Article

Note: The datasets during and/or analyzed during the current study are available from the corresponding author upon reasonable request. The authors received a Curriculum Development Fund from the Department of Emergency Medicine at London Health Sciences Centre in the amount of $6220 to create interactive virtual cases for emergency physicians during the COVID-19 pandemic. Code Silver was included as one of seven of these virtual cases.


  1. Kim, J.J., Howes, D., Forristal, C. et al. The Code Silver Exercise: a low-cost simulation alternative to prepare hospitals for an active shooter event. Adv Simul 6, 37 (2021).

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