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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Weapons and Controlled Substances
Policy Number: 4.26
Effective Date: November 1, 2016
Chapter: Legal Services
To provide procedures for handling situations in which an unauthorized weapon or controlled substance is
observed in or at a UW Health facilities.
Weapons: Items or materials capable of inflicting harm. Weapons may include but are not limited to
knives, stabbing instruments, electronic incapacitating devices (stun guns), and firearms. Weapons also
include chemical incapacitating agents. The definition of “weapon” for this policy is not limited to items
considered “weapons” under the state concealed carry law.
Controlled Substance: Drugs and other substances that are considered controlled substances under the
Controlled Substances Act (CSA).
III. POLICY ELEMENTS
A. Whenever a staff member is aware that a person has in his or her possession a weapon
or controlled substance that is not permitted under this policy, this procedure should be
B. Controlled substances may be possessed and used for patient care and research purposes as
permitted by law. All other possession or use of controlled substances in UW Health facilities is
C. Possession or use of weapons by anyone is prohibited in UW Health facilities, except as
authorized by this policy.
1. Authorized possessions and use
a. Law enforcement officers performing official duties may possess and use
weapons for such official duties.
b. Tools being used by hospital staff and contractors in the performance of their
official duties are permitted. Medical devices and other equipment provided by or
authorized by UW Health which are being used for authorized clinical or
research or patient care are permitted. Firearms are not permitted to be used as
tools or equipment. With the approval and written permission from the Director
of Security Services firearms may be used for educational and/or research
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c. Armed personnel filling ATM machines.
d. UW Health Security may possess, but not use, weapons when transporting or
securing weapons found on UW Health facilities.
2. UW Health staff, patients and visitors may possess Oleoresin Capsicum (Pepper Spray) at
a concentration allowed by law, for personal protection outside of UW Health properties,
provided they do not use or threaten to use the devices in a UW Health facility or act in a
manner that is otherwise threatening or exhibit lack of control of behavior, except UW
Health Security staff may use such devices in the course of their duties when consistent
with use of force department policy.
A. Confiscation of Controlled Substance
1. Whenever a Schedule I Controlled Substance (e.g., hallucinogens, heroin, marijuana) or
an unauthorized Controlled Substance on Schedule II (cocaine, amphetamines, morphine,
barbiturates, phenobarbital, etc.), comes to the attention of a UW Health staff member
they should not place themselves at risk. UW Health Security should be called and the
area supervisor should be notified.
2. If the unauthorized Controlled Substance is obtained, the material should be placed in an
envelope and sealed. If the material is from a patient, the patient's name, number and
other identifying information should not be placed on the envelope. If the material is
from a non-patient, identifying information may be placed on the envelope. If there is a
question about whether a substance is authorized, the Administrator on call should be
3. After it is determined that the substance is unauthorized, UW Health Security should be
notified and will pick up the sealed envelope with the confiscated material in it and take
care of disposal of the material in accordance with Security Department policy.
4. A Patient Safety Net (PSN) report should be submitted following all events involving
confiscation of unauthorized controlled substances using the Behavioral Event type and
under contraband unauthorized objects.
B. Weapons in the possession of Employees-All employees are prohibited from bringing weapons
into or onto a UW Health facility. Security should be immediately contacted. Security will
dispatch an officer to assess the situation and assist staff. Security will make decisions based on
Security Department protocol. Under no circumstances should other UW Health staff members
attempt to confiscate or accept possession of a weapon from an employee.
C. Weapons in the possession of non-employees at UW Health properties
1. Non-threatening situations
a. In non-threatening situations, staff must notify a manager/supervisor whenever
an unauthorized weapon is observed in a UW Health facility that is not in the
possession of an individual as described in Section III C.1.
b. To prevent accidental discharge of firearm or other unintended injury, staff will
not attempt to remove, handle or otherwise manipulate the weapon.
c. A manager/supervisor, who knows the situation, feels comfortable with dealing
with the situation and does not feel that the situation is threatening, may explain
to a patient visitor that the weapon is not permitted in the facility and ask that the
weapon be taken out of the building. Managers/supervisors are not required to
address patient/visitors. If there is discomfort or additional assistance is needed,
Security should be immediately contacted. Security will dispatch an officer to
assess the situation and assist staff. Security will make decisions based on
Security Department protocol.
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d. Staff should not allow persons with weapons to proceed into exam rooms or
treatment areas, except in the emergency department and limited to the situation
described in this subsection. Patient appointments should be postponed until the
situation is resolved. Emergency department screening and services should not be
delayed except to the extent necessary to deal with actual threatening behavior.
e. Any problem or conflict over the weapon or its possession will be resolved
between the individual and Security or local law enforcement. Under no
circumstances should a UW Health staff member attempt to confiscate or accept
possession of a weapon from an individual, except that Security staff may accept
temporary possession in some circumstances for safe keeping.
f. A PSN should be submitted following all events involving weapons or
confiscation of weapons using the Behavioral Event type and under contraband
2. Threatening situations
a. If an individual with a weapon becomes threatening or disruptive, or is perceived
by staff to be a threat, staff should activate the Active Violent Intruder Response
Plan and immediately (call 911) and initiate the “Out Strategies” used in the
Active Violent Intruder Response Plan. Get Out, Call Out, Hide Out, Take Out.
b. A PSN should be submitted following all events involving weapons or
confiscation of weapons at UW Properties.
D. The Administrator on call should be notified if there are questions about the confiscation
procedure and/or if sensitive issues arise during confiscation of controlled substances and
V. RELATED POLICIES
Hospital Administrative Policy 9.58 – Workplace Violence Reporting, Investigation and Discipline (See
II.C.2 on storing weapons in vehicles.)
Sr. Management Sponsor: SVP, Chief Legal Officer & General Counsel
Author(s): Director, Risk Management; Director, Security
Reviewer: Legal Services
Approval Committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 112013
Next revision: 112019