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Proposing a Possible [San Bernardino CA] Medical Work Place Violence Prevention Initiative?

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The Haddon Matrix for Health Place Injury Prevention and Workplace Violence


[Eugene Schmukler; PhD MBA MEd – Certified Trauma Specialist]


An invaluable tool for healthcare violence prevention program establishment is the Haddon Matrix. In 1968, William Haddon, Jr., a public health physician with the New York State Health Department, developed a matrix of categories to assist researchers trying to address injury prevention systematically. The idea was to look at injuries in terms of causal factors and contributing factors, rather than just using a descriptive approach. It is only recently that this model has been put to use in the area of workplace violence.

The Matrix Framework

The matrix is a framework designed to apply the traditional public health domains of host, agent, and disease to primary, secondary, and tertiary injury factors. When applied to workplace violence, the “host” is the victim of workplace violence, such as a nurse. The “agent” is a combination of the perpetrator and his or her weapon(s) and the force with which an assault occurs. The “environment” is divided into two sub domains: the physical and the social environments. The location of an assault such as the ER, the street, an examining room, or hospital ward is as important as the social setting in patient interaction, presence of co-workers, and supervisor support.


Subsequent versions of the matrix divide the environment into Physical environment and Social, Socio-economic, or Sociocultural environment. Each factor is then considered a pre-event phase, an event phase, and a post-event phase.




Medical / Healthcare Setting

The Haddon Matrix lends itself to a medical setting in that it uses a classical epidemiological framework to categorize “pre-event,” “event,” and “post-event” activities according to the infectious disease vernacular, host (victim), vector (assailant or weapon), and environment. The strength of the Haddon Matrix is that it includes the ability to assess “pre-events” or precursors in order to develop primary preventive measures.





Physical Environment

Social Environment

Pre-event (prior to assault)




History of prior violence communicated

Assess objects that could become weapons, actual weapons, egress (means of escape)

Visit in pairs or with escort

Event (assault)


Escape techniques

Alarms/2-way phones

Reduce lethality of patient via increasing your distance

Egress, alarm, cell phone

Code and security procedures

Post-event (post-assault)

Medical care/counseling

Post-event debriefing


Law enforcement

Evaluate role of physical environment

All staff debrief and learn

Modify plan if appropriate



From the perspective of administration, the Haddon Matrix does not implicate policy. This means that the matrix does not necessarily guide policy. When implemented, the Haddon Matrix can be a “politically” neutral, trans-or multi-disciplinary, objective tool that identifies opportunities for intervention. Furthermore, it outlines sensible “targets of change” for the physical and social environment.



Affected individual and population

Agent used



Psychological first aid

Communicate efforts to limit action

Have plans in place detailing agency roles in prevention and detection


Population uses skills

Mobilize trauma workers

Communicate that response systems are in place


Assessment, triage, and psychological treatment

Communicate, establish outreach centers

Adjust risk communication

End results

Limit distress responses, negative behavior changes and psychological illness

Minimize loss of life and impact of attack

Minimize disruption in daily routines


More: Was the San Bernardino CA Massacre Work Place Violence?


Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™    8Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™



And so, was San Bernardino workplace violence – or not; please opine?


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4 Responses

  1. Bullying in the Hospital

    Link for more info:



  2. Impaired Doctors

    A large survey of American doctors has found that more than one-third would hesitate to turn in a colleague they thought was incompetent or compromised by substance abuse or mental health problems.

    However, most physicians agreed in principle that those in charge should be told about “bad” physicians.

    AMA report link: http://jama.ama-assn.org/cgi/content/short/304/2/187



  3. The Haddon’s Matrix

    I truly believe the Haddon’s Matrix is a proven framework for injury prevention.


    Nevertheless, this 40 plus matrix framework has now evolved into other related discipline such as youth violence, etc.

    Ken Yeung MBA CMP™ candidate


  4. The Haddon Matrix

    The HM is the most commonly used paradigm in the injury prevention field.

    Developed by William Haddon in 1970, the matrix looks at factors related to personal attributes, vector or agent attributes and environmental attributes; before, during and after an injury or death. By utilizing this framework, one can then think about evaluating the relative importance of different factors and design interventions.

    Ann Miler RN MHA


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