Mitigation activities or controls are any actions taken to permanently eliminate or reduce the risk of hazards to human life, property, and function. The four basic mitigation activities are as follows:

  1. Deterrent controls reduce the likelihood of a deliberate attack and/or dissuade would-be attackers by making a facility less desirable as a target.

  2. Preventive controls protect vulnerabilities by making an attack unsuccessful or reducing its impact.

  3. Corrective controls reduce the effect of an attack.

  4. Detective controls discover attacks and may trigger preventive or corrective controls.

Combining Risk Assessments and Mitigation Initiatives

A more sophisticated method of conducting risk analysis and assessing mitigation initiatives is a failure modes and effects analysis (FMEA) (Electronic Industries Association 1971). Developed by the U.S. military in 1949 as a reliable evaluation technique to determine the effect of system and equipment failures (U.S. Armed Services 1984), FMEA systematically identifies potential system failures, their causes, and the effects on the system’s operation. It is most often used to proactively assess the safety of system components and to identify design modifications and corrective actions needed to mitigate the effects of a failure on the system.

The FMEA process can be a valuable tool in improving internal preparedness for response to emergencies or disasters of any sort and has been endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). When the analysis is extended to include an assessment of the failure mode’s severity and probability of occurrence, the analysis is called a failure mode, effects, and criticality analysis (FMECA).

An example of the FMECA process applied to routine hospital operations might be patient admissions through the emergency department. To admit a patient, a number of functions must occur: an accepting physician must be identified and contacted, initial orders must be provided to the accepting floor or ward, administrative and clerical work accompanying the admission must be completed, a bed and the nursing staff must be prepared to accept the patient, and the patient must be delivered to the floor or ward. A defined failure might be the inability to admit the patient within one hour of the determination that admission is warranted. By analyzing the processes involved with getting the patient admitted, failure modes can be identified (e.g., inordinate delay in preparing the patient’s room), and the root cause of these failure modes can be further elucidated. If the cost of the failure mode is sufficient (e.g., patient or staff dissatisfaction), procedures may be modified, additional staff may be hired, or other actions may be taken to improve this process.


Many chapters of this book outline an approach to preparedness and planning for a terrorist event involving WME in more detail; however, three overarching principles for optimal preparedness of the healthcare sector cannot be overemphasized: integration, testing, and resources.


Planning and preparedness for any disaster cannot be done in isolation, nor can hospitals develop plans based on untested assumptions of what other response agencies (fire services, law enforcement, etc.) will or will not do in a disaster response. Similar agencies must plan as a unit. In the event of a large-scale catastrophe, all hospitals will be involved, and thus area facilities must plan as though they are part of a regional network.

The healthcare sector encompasses much more than hospitals. Primary care clinics and private physicians, emergency medical services, private ambulance companies, community and state public health agencies, pharmacies, veterinary clinics, urgent care centers, long-term-care facilities and hospices, funeral homes, medical vendors and warehouses, and many other business concerns have both potential roles and a stake in the success of response operations. These potential sources of staffing and material resources must be included in planning and preparation. Integration and interoperability are discussed in further detail in other chapters of this book.


Modeling and simulation for terrorist events have historically been based on large-scale events that would rapidly overwhelm the local response system’s capacity, requiring the utilization of state and federal resources. Although this may be a valid test of vertical integration (the ability to incorporate regional, state, and federal resources into local disaster operations), another rarely used approach is to determine the system’s actual time-phased functional capability and capacity.

This methodology seeks to determine the resources actually required from all response sectors at a given period of time after the incident and may be of particular value because it could be used to establish the trigger required to activate and release these higher-level resources. Prospective determination of a system’s capacity allows a “high-water line” with which to compare an actual event as it unfolds, allowing more accurate needs assessments and requests for assistance that drive the state and federal responses.


It is unreasonable to expect the healthcare sector to expend resources they do not have or to amass large quantities of excess expirable supplies based on a low-probability event. Unlike the majority of emergency response organizations, the healthcare sector has historically received little or no funding from the public coffers for disaster preparedness and mitigation. The December 2003 Homeland Security Presidential Directive/HSPD-8 includes “clinical care” among its defined “first responders,” and healthcare is a first-responder discipline listed in budgets for fiscal year 2004 Office of Domestic Preparedness grant monies. This will allow the healthcare sector to use the grant money for planning, organizing, equipping, training, and exercising (The White House 2003).

Recent legislation has allotted some funding to improvements in state and community public health agencies, and a small percentage of this funding is designated for traditional healthcare operations. Businesses involved with healthcare operations should gain the support of local and state governments for a share of disaster preparedness funding if the communities can reasonably expect full participation in planning for these events.

Weapons of mass effect pose a challenge that the healthcare sector has not seen in the history of this country. Federal resources are necessary; however, these events would be first and foremost local calamities, and the local healthcare system will be part of the vanguard of response. Mitigation, planning, resource procurement, education, and training are required if this critical partner in response is to be prepared for these events.

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