Haddon’s Matrix and Falls Prevention

Submitted by Melville D. Bradley

Tags: fall fall care fall prevention falls patient room

 Haddon’s Matrix and Falls Prevention

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Haddon’s Matrix is an injury prevention and investigation tool that is used to analyze adverse events, close-calls, or anticipated adverse events in order to recommend preventive strategies to protect the population in which the event occurred or could occur.  It is composed of two dimensions with rows equating to the three levels of adverse event prevention and columns consisting of the components of the epidemiological triad of host, agent and environment (Figure1a),[1].  The matrix cells are filled with preventive strategies and / or contributing factors that correspond to these three levels of an adverse event as a function of the epidemiological triad; it can provide a manageable framework for either brainstorming post events / post close-call events, or to pre-plan preventive strategies concerning anticipated adverse events. The general terms of pre-event, event, and post-event guide more specific terms.  For example, concerning patient falls, the three event phases would be recast as pre-fall, fall, and post-fall.  Originally used for motor vehicle accidents, Haddon’s matrix has subsequently found many applications ranging from public health issues and disaster preparedness,[2], to snowboarding injuries,[3].  A 2014 PubMed / EBSCO search revealed articles incorporating the Haddon matrix in water safety and drowning prevention,[4], pre-hospital patient safety,[5], and hospital sharps injury risk,[6].  Brasel, Layde, & Hargarten (2000) also showed the utility of the matrix in evaluating a surgical error of wrong-side chest tube placement in a trauma victim in an emergency department,[7].  A systems based variant of the Matrix appropriate for patient safety issues has been used by the author in post-fall huddles and  RCAs (Figure 1b). 

The use of Haddon’s matrix is complemented by Haddon’s countermeasures,[8]:  (1) Prevent the creation of the hazard in the first place, (2) Reduce the amount of hazard brought into being, (3) Prevent the release of the hazard that already exists, (4) Modify the rate or spatial distribution of release of the hazard from its source, (5) Separate the hazard from that which is to be protected by time and space, (6) Separate the hazard from that which is to be protected by a physical barrier, (7) Modify relevant basic qualities of the hazard, (8) Make what is to be protected more resistant to damage from the hazard, (9) Begin to counter damage done by the hazard, and (10) Stabilize, repair, and rehabilitate the object of damage.  These countermeasures can serve as a guideline to filling in the matrix cells for preventive action for a given or anticipated event.  The preventive strategies within the matrix cells can be classified as either weak fixes (administrative controls) or stronger fixes (elimination, substitution, or engineering controls) based on the traditional industrial hygiene hierarchy of controls (Figure 1b). As an investigation progresses, matrix cell content may be altered, eliminated, or added resulting in greater clarifications.   An example of Haddon’s countermeasures using patient falls as an example is shown in Table 1. 

The matrix may be used for pre-planning if an incident is anticipated, close-call work-ups, incident investigations, after action reports, and post corrective implementation evaluations (Barnett, et al., 2003); as well as brainstorming, organization of an investigation, addressing and framing relevant questions, and to delineate early what controls are in place, what controls may need to be added, and what controls may need overhaul.       


  1. Haddon W.  Advances in the epidemiology of injuries as a basis for public policy.  Public Health Reports 1980;95(5):411-421.
  2.  Barnett DJ, Balicer RD, Blodgett D, et al. The application of the Haddon matrix to public health readiness and response planning.  Environmental Health Perspectives 2005;113(5):561-566.
  3.  McKenna J, Hammond C. Perspectives on injuries in snowboarders.  J. R. Soc. Promot Health 2007;127(4):181-189.
  4.  Cortes LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travelers.  Journal of Travel Medicine 2006;13(1):21-34.
  5.  Meisel ZF, Hargarten S, Vernick J. Addressing pre-hospital patient safety using the science of injury prevention and control.  Pre-hospital Emergency Care 2008;12(4):411-416.
  6.  Ganczak M, Barss P, Al-Marashda A, et al. Use of the Haddon matrix as a tool for assessing risk factors for sharps injury in emergency departments in the United Arab Emirates.  Infection Control and Hospital Epidemiology 2007;28(6):751-754.
  7.  Brasel KJ, Layde PM, Hargarten S. Evaluation of error in medicine: Application of a public health model. Academic Emergency Medicine 2000;7(11):1298-1302.
  8.  Haddon W.  The changing approach to the epidemiology, prevention, and amelioration of trauma:  The transition to approaches etiologically rather than descriptively based.  American Journal of Public Health 1968;58:1431-1438.

Figure 1.   (a)  General framework of Haddon’s matrix


Host/Personal Factors



Physical Environment


Social Environment


Pre-event  factors

(primary prevention strategies)





Event factors

(secondary prevention strategies)





Post-event  factors

(tertiary prevention)





(b) Matrix variant

Hierarchy of controls ordered from strongest to weakest:

(1)     Elimination

(2)     Substitution

(3)     Engineering

(4)     Administrative

(5)     Personal Protective Equipment (PPE)

-Controls in place before event* (pre-event factors)


-controls already in place (if any)


*(For patient/personal factors row: consider pre-existing risks, co-morbidities, and protective factors)

-Why did event happen? (event factors)


-failure of controls

-control method vulnerabilities


-new unforeseen problems

-lack of controls in place


-What do we do to prevent a similar event from occurring? (post-event factors)


-improve level of control(s) based on controls hierarchy

-create new controls

-replace ineffective, or potentially unsafe controls

-Patient / personal factors




-Communication factors




-Training factors




-Fatigue / scheduling / staffing factors




-Environment / Equipment factors




-Rules / Policies / Procedures factors





-Barrier issues




Table 1.  Some examples of falls countermeasures

(1) Prevent the creation of fall conditions:

  • eliminate slip / trip hazards
  • optimize medication dosages to prevent medication related postural hypotension
  • engineer patient room lighting to ANSI stds.
  • administrative control using sitters / toileting escorts

(2) Reduce the amount of fall conditions brought into being:

  • engineer non-slip floor surfaces in rooms
  • non-slip socks
  • room railings
  • wheelchair seatbelt use
  • policies on room maintenance and cleaning
  • patient training on wheelchair use
  • policy on patient escorts / sitters / comfort rounds

(3) Prevent the release of fall conditions (gravity):

  • wheelchair seatbelt use
  • safe patient handling technologies (specifically, properly maintained lifts)

(4) Modify the rate of release of fall conditions (gravity):

  • seatbelt / restrain use
  • lower bed heights
  • assisted fall procedure

(5) Separate fall conditions from that which is to be protected by time and space:

  • toileting escort
  • sequestering bedside fall protection mats during the day while patient is awake and active.
  • clutter free pathways

(6) Separate fall conditions from that which is to be protected (patient) by a physical barrier:

  • hip protectors
  • helmet
  • fall injury protection bedside floor mats      

(7) Modify relevant basic qualities of fall conditions

  • engineer floor power cord coverings, or use covered floor trenches for cords
  • mop on night shift while most patients asleep, hence reducing wet slip conditions

(8) Make what is to be protected (patients) more resistant to damage from fall conditions:

  • stop smoking (less osteoporosis risk)
  • exercise regimen
  • how to fall properly training
  • PPE such as hip protectors, helmets, restraints
  • patient meds (drowsiness, dizziness, etc) addressed
  • patient medical conditions addressed

(9) Begin to counter damage done by fall conditions:

  • RCA / aggregate review process
  • interim fixes to prevent falls before permanent fixes can be implemented        

(10) Stabilize, repair, and rehabilitate the object of fall conditions damage

  • patient treatment of fall related injury(s)
  • rehabilitation
  • disability evaluation