Introduction

Today, accidents and disasters have taken up a large part of the resources and programs of governments. Every day, the media carries information about various accidents worldwide, and statistics show a growing increase in accidents in every corner of the world. More than 90% of deaths in developing and underdeveloped countries are caused by accidents and disasters. Iran is a developing country in Asia prone to various natural and artificial accidents and disasters, and is considered one of the most vulnerable countries in the world.1 CBRNE incidents involve the uncontrolled release or use of chemical, biological, radiological, nuclear, or explosive materials, often causing mass casualties, societal disruption, or environmental damage through accidents, terrorism, or military actions.2 Currently, the level of awareness of the use of chemical, microbial, and nuclear agents in everyday industrial and non-industrial CBRNE accidents has increased.3 Formulas and instructions for producing many chemicals that can have military or terrorist applications are safely available to everyone in written sources, especially on the Internet and virtual networks, without supervision. On the other hand, vast amounts of dangerous chemicals are produced, transported, stored, and used for industrial and domestic purposes every day.4

Health is the first and most important demand and concern of people in such incidents. Therefore, the health sector has a special place among all the elements involved in managing incidents and disasters.1 Hospitals and health center staff are also directly affected by incidents and crises.5 In fact, hospitals are the most pragmatic units in the health care system by attracting the most material and human capital.6 In general, hospitals, as fixed and specialized centers providing medical services with facilities and experienced staff, are considered one of the essential components of the response process to unexpected incidents, which are responsible for preserving the lives and health of the injured.5

CBRNe incidents can be catastrophic, making preparedness essential for healthcare systems; disaster preparedness involves protective measures before, during, and after incidents. Hospital preparedness plus staff readiness are vital for managing emergencies, including CBRNe events, with a well-developed emergency response plan to avoid disorganization. So holistic, well-structured risk management system is necessary for health systems to understand, learn from, and address systematic risks.7–10

Risk management in healthcare involves identifying, assessing, and controlling risks to reduce negative impacts on patients, staff, and facilities. It is crucial in hospitals to prepare for and respond to adverse events through strategic planning, expert input, and holistic approaches. This process helps mitigate threats, supports safety and resilience, and also enables value creation and innovation, especially in the context of evolving challenges like CBRNE incidents.11

On the basis of the results of some investigations, six main challenges of “management and leadership”, “planning”, “prevention and mitigation”, “preparedness”, “response”, and “recovery” in the field of in military hospitals exist. Also poor communication and coordination in the crisis team are among the most critical challenges in military hospitals.12

In the face of (CBRNE) events in military hospitals, risk management is of particular importance as a critical boundary between the efficiency of health services and the sustainability of military operations. Identifying the strategic dimensions and components of risk management in CBRNE incidents creates a systematic and organized format that allows hospitals to act efficiently in the face of various threats, mainly chemical, biological, radiological, nuclear, and explosive CBRNE incidents, and prevent irreparable damage. Therefore, risk management in hospitals, in addition to the medical aspect, also includes other elements to provide the necessary preparedness in all areas. This research, with descriptive exploratory approach, examines which strategic dimensions in risk management in military hospitals are more important and have executive priority for facing CBRNE events and how they are effectively applied in policymaking or organizational-level decision-making. It helps to provide policy frameworks and management approaches to provide an effective and sustainable response to CBRNE events in military hospitals.

Methods

The study was conducted in 2025 by using a qualitative method, descriptive exploratory approach and guided framework analysis. Semi-structured interviews sessions were conducted to identify the strategic components and dimensions of risk management in dealing with CBRNE events in military hospitals, from the perspective of experts in this field (academic officials and university faculty members). The sampling was purposive and heterogeneous (participants with maximum diversity) and continued until sufficient data were collected. This method seeks to collect data from participants with rich information and adequate experience in the phenomenon under study, and those who desire to participate. The inclusion criteria for the study were having at least 5 years of executive experience and a willingness to participate. An interview guide was developed for the interview, and the interviews were conducted based on it. The interview questions were about what key dimensions and components, experts and officials suggest in the field of preventing or reducing vulnerability, preparedness, response, and recovery from CBRNE incidents. About 14 interviews were conducted with an average time of about 40±15 minutes. After obtaining the consent of the participants in the study, their views were recorded and implemented immediately after the completion of each interview. The framework analysis method was used to analyze the data (Table 1).

Table 1 Profile of Interviewees (Expert & Experience)

The process of framework analysis method consists of five stages (Data Familiarization, Identifying a Thematic Framework, Indexing, Charting, Mapping, and Interpretation):13

Data Familiarization

In this stage, after the researchers became acquainted with the transcripts from interviews, they developed an overall understanding of the data. In this stage, the research objectives were reviewed to ensure that the collected data were aligned with the aims of the study.

Identifying a Thematic Framework

During the familiarization process, ideas that emerged while reading the transcripts were extracted. To organize a thematic framework, recurring ideas identified during familiarization were grouped into clusters of similar ideas or developed into themes. At this stage, the researchers developed a thematic framework specifically for the dimensions of prevention, preparedness, response, and recovery was modeled based on existing literature and documents.

Indexing

This involves identifying units or segments of data that are related to a specific theme. This stage includes reviewing the transcripts and interview notes and noting the themes present within the data. In this stage, two researchers analyzed the data to help reduce bias and increase accuracy. Both researchers transcribed, coded, and analyzed all data. The extracted codes were then categorized into themes and subthemes based on comparisons of similarities and differences.

Charting

After indexing the data according to the thematic framework, the data were summarized in thematic tables. This means that a summary of the original data was placed in the cells of the table, allowing all the data to be viewed in one place. The ease of viewing the data in a table helps the researcher interpret the information more effectively and pay closer attention to data that may lack clarity.

Mapping and Interpretation

The final stage involves presenting a map and providing a comprehensive interpretation of the data in order to synthesize them. In this phase, the tables are reviewed to gain an overall understanding of the entire dataset. Data synthesis involves defining concepts, illustrating the relationships between them, clarifying the nature of the phenomenon, and providing explanations and recommendations. These concepts and relationships should be derived from the perspectives, beliefs, and values of the participants. This stage enables the research team to compare and interpret participants’ perspectives and interpretive patterns regarding the phenomenon under study.

The member checking method was used to examine the validity of the study. To check the validity, the transcripts were given to four participants to ensure their accuracy, and their comments were applied after review by the research team. Also, two researchers reviewed the initial codes, subthemes, and main themes, and then the results were confirmed. To ensure the transferability of the data, purposive sampling and rich data description were used.

In this study, ethical issues were observed, including obtaining permission from the Ethics Committee of Baqiyatallah University of Medical Sciences (IR.BMSU.BAQ.REC.1403.202), obtaining permission from the university’s Vice Chancellor for Research, providing sufficient information at the beginning of the study to inform participants of what was going to be done, obtaining written informed consent for data collection and voluntary participation of individuals to participate in the study, the freedom of experts to cooperate or not to cooperate in the study, respect for the independence and decision-making of participants, and non-publication of the names of participants in the research.

Results

Risk management in CBRNE incidents in military hospitals requires a comprehensive approach at four levels of risk management, including prevention, preparedness, response, and recovery. In the area of prevention and vulnerability reduction, key dimensions and components of risk management include management framework and leadership, asset and supply chain management, technical and equipment capacity building, incident prevention and mitigation, training, practice, and safety culture, response and continuity of operations, cybersecurity, and privacy. (Table 2).

Table 2 Key Dimensions and Components of Risk Management in Preventing the Occurrence and Reducing Vulnerability to CBRNE Incidents

In preparedness and vulnerability reduction for CBRNE incidents, it is essential first to have a clear management and leadership framework. Risk assessment aligned with operational priorities aligns operational planning and resource allocation. At the operational level, we need operational readiness and continuous training, adequate technical and logistical readiness, and a sustainable safety culture that also includes employees’ mental health. Cybersecurity and data protection also ensure that a rapid and secure response to threats is carried out and information privacy is maintained (Table 3).

Table 3 Key Dimensions and Components of Risk Management in CBRNE Incident Preparedness

In response to CBRNE incidents, key dimensions of risk management include the command and control framework (ICS/IMS), detection, screening, and triage, personnel safety and workplace protection, scene management and isolation, resource and logistics management, clinical processes and continuity of care, and continuous learning, review, and improvement (Table 4).

Table 4 Key Dimensions and Components of Risk Management in Response to CBRNE Incidents

In CBRNE incident rehabilitation, key dimensions include post-event assessment and review of protocols and processes through AAR (As-done Review), along with employee health and mental health management, post-incident supply chain and logistics management, and cleanup, decontamination, and restoration of the workplace. Rehabilitation assessment processes and criteria should include critical indicators. Communication with stakeholders and the community is also essential to maintain transparency, public trust, and cooperation in rehabilitation. Assessing the long-term risks of exposure to CBRNE materials, implementing safety measures, and updating protocols are also essential components (Table 5).

Table 5 Key Dimensions and Components of Risk Management in Rehabilitation in CBRNE Incidents

Discussion

Risk management in CBRNE incidents in military hospitals involves a comprehensive and multidimensional approach designed to effectively mitigate risks and ensure the safety and care of casualties.12 This approach, at four levels of risk management including prevention, preparedness, response, and rehabilitation, enables military hospitals to function as treatment centers and as CBRNE crisis management centers with effective preventive, preparedness, and response capabilities.

In prevention and vulnerability reduction, management frameworks are crucial to enable organizations to effectively manage complex risks and thus ensure resilient and sustainable performance in the face of CBRNE threats.14 Asset management in healthcare facilities requires a multi-layered approach that includes physical and cyber security measures.15,16 Effective supply chain risk management is also crucial to maintain the integrity and security of these materials during storage, transportation, and use.14 Technical and equipment capacity building in CBRNE incident risk management includes equipping operational teams with personal protective equipment (PPE), decontamination kits, hazardous materials identification equipment, and physical and data security systems, which should be accompanied by continuous training and updating of experts’ knowledge.15 Efforts to prevent incidents and reduce their likelihood of occurrence are possible by reducing the risks of unauthorized access and misuse, and designing secure processes.14 Conducting training and crisis simulation exercises and creating a safety culture ensures long-term employee motivation and readiness.17 Continuity of operations is maintained through ongoing risk assessments, capacity building, resource management, and response protocols, enabling threat management as emphasized in authoritative guidelines and tools. Various malicious actors can carry out18 Cyber threats to create fear, damaging infrastructure. Standard practices, awareness, training, and strong legal frameworks are needed to reduce vulnerabilities, increase cyber resilience, and tightly control access to data and systems at all operational levels.19

In the area of preparedness, a clear management and leadership framework is essential to clarify roles, responsibilities, and decision-making processes, align operational planning, and allocate resources with risk assessment based on operational priorities.14 CBRNE risk assessment frameworks are a comprehensive and systematic process that helps to safely and effectively manage threats posed by sensitive materials and include the design of various mechanisms from identification to response.14 Operational preparedness requires continuous training, adequate technical and logistical support, and a sustainable safety culture that includes mental health considerations for personnel.20 Regular training exercises,17 updating response plans,18 and strengthening technical and logistical infrastructure, such as equipment and strategic reserves, along with safety standards, data documentation, cybersecurity, and data protection, ensure a rapid and safe response while maintaining information confidentiality.14,19

In response to CBRNE incidents, a command and control management (ICS/IMS) framework is also essential, as it clarifies roles, responsibilities, and decision-making processes and enables a coordinated and efficient response to the incident.14 Detection, differentiation, and prioritization in the face of CBRN incidents include rapidly identifying chemical, biological, radiological, and nuclear hazardous agents using specialized equipment and spot tests.21 Personnel safety and workplace protection in CBRN risk management require complete adherence to appropriate personal protective equipment and the implementation of safety protocols to minimize exposure to hazardous agents during scene management.22 Areas within the hospital are divided into three main zones: the contaminated zone (HOT), where contact with hazardous materials occurs, the contaminated zone (WARM), where personnel and equipment are prepared for decontamination measures, and the clean or non-threat zone (COLD), which is safe and free from contamination. Each area has designated entry and exit routes to control access and prevent the spread of contamination. In addition, communication channels are established with relief and security units to exchange information and coordinate resources.23 Efficient supply chains and critical support systems ensure timely coordination with suppliers, support camps, and relief networks to quickly provide essential resources, facilitating effective response and continuity of care.24 Continuity of care for routine and emergency patients in CBRNE incidents includes designing separate treatment lines to prevent cross-contamination between CBRNE incident patients and others.25 In addition, staff mental health support programs focus on regular breaks, psychological counseling, and fatigue management to maintain team effectiveness and well-being during crises.26 Lessons learned in CBRNE incident management include using previous experiences to enhance response effectiveness.14 Periodic reviews and continuous optimization are conducted through regular planning, evaluation of key performance indicators, revision of protocols, and evaluation of infrastructure. This constant cycle of reflection and improvement ensures that preparedness capabilities evolve in line with emerging threats and lessons learned from real-world incidents and exercises.14

Rehabilitation of CBRNE incidents includes monitoring delayed health effects, managing psychological impacts on responders, and integrating lessons learned to increase future preparedness and resilience.2 Managing employee health and mental health in CBRNE risk management includes ongoing physical and psychological assessment of personnel, using individual and group counseling to reduce stress and provide psychological support, and rehabilitation programs for a gradual return to work. Training and preparing employees for CBRNE threats through specialized courses and creating a supportive environment are essential to promote their resilience and health.2 Cleanup, decontamination, and remediation in CBRN risk management are critical processes that aim to remove or neutralize hazardous agents from people, equipment, and environments to ensure safety and prevent secondary contamination.27 Evaluating the effectiveness of actions taken and comprehensively documenting lessons learned helps to continuously evaluate and revise protocols and processes, forming a reliable organizational learning cycle that includes individual learning, mental models, organizational memory, and environmental feedback.28,29 Supply chain management involves continuously monitoring inventory, assessing expiration and usability, and ensuring rapid replenishment to maintain readiness. Efficient supply chain coordination and deployment protocols ensure timely access to critical emergency resources for optimal protection and patient care.30 Effective stakeholder and community communication in CBRN risk management is essential for a coordinated response and public trust. This includes transparent information sharing, multi-agency collaboration, and tailored messaging to address diverse audience needs, increasing preparedness and reducing misinformation during crises.31 Resilience assessment processes in CBRNE risk management include analyzing the performance of the response system, identifying strengths and weaknesses, and reviewing the effectiveness of ongoing training and exercises. Resilience measures focus on improving team capabilities, ensuring employee safety, and enhancing equipment and operational capacities, which are achieved through ongoing assessments and organizational reviews.22 Ongoing personnel training, frequent workplace safety assessments, and assessing long-term risks of exposure to CBRNE materials are among the most critical factors in ensuring employee health and the effectiveness of the response to CBRNE incidents.23

The proposed framework for risk management of CBRNE incidents in military hospitals is not a simple collection of prevention, preparedness, response, and rehabilitation activities. It is a tightly integrated system where each domain reinforces and amplifies the others, creating a resilient and adaptive hospital ecosystem. Prevention reduces likelihood and impact, informing targeted preparedness and robust risk assessment; preparedness provides clear leadership, continuous training, and enduring safety culture that enable a swift, coordinated response; the response component establishes structured command, optimized zone control, secure supply chains, and effective communication, which in turn safeguard ongoing operations and patient care; rehabilitation closes the loop by monitoring long-term health outcomes, supporting responders, and incorporating lessons learned back into planning, training, and structural improvements. This integration yields synergistic benefits: faster detection and containment, safer care pathways, preserved personnel health and morale, stronger organizational memory, and a dynamic capacity to evolve with new threats. In sum, the framework’s interdependencies enable sustained operations, rapid recovery, and continuous improvement.

Conclusion

Policymakers and managers of universities and military hospitals should take a practical improvement approach to prevention, preparedness, response, and recovery. In prevention, we can improve supply chains and assets by implementing strong management and leadership frameworks, developing technical capacities, and establishing a safety and mental health culture among employees by establishing a risk management working group, publishing an annual risk assessment and planning to reduce risks enables faster identify and reduces technical and operational risks. In the area of preparedness and response to incidents, by standardizing Incident Specific Operating Procedures aligned with Incident Command System, regular exercises, strengthening a safety culture, and comprehensive support, also resource planning and ongoing training, we can maintain operational readiness, ensure adequate technical and logistical provision, and foster a sustainable safety culture so that effective command-and-control and clinical processes with continuity of care are possible and operationally applied in the face of incidents. At the recovery level, post-event assessment, protocol review through After Action Review, post-incident supply chain management, and workplace cleanup can ensure efficient recovery and use vital indicators as evaluation criteria. Also, continuous communication with stakeholders and the community is needed to maintain transparency and public trust, and safety measures should be implemented to address the long-term risks of CBRNE exposure. Ultimately, these integrated and interconnected approaches strengthen the resilience and preparedness of the military hospital health system against future threats and provide continuous improvement through continuous protocol updates and continuous learning.

Ethical and Consent Statements

This study was approved by the Research Ethics Committee of Baqiyatallah University of Medical Sciences (Code: IR.BMSU.BAQ.REC.1403.202). The participants of study informed consent included publication of anonymized responses/direct quotes.

Acknowledgments

The authors thank the Baqiyatallah University of Medical Sciences, Tehran, Iran, for support of this study.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declared no conflicts of interest in this work.

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