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Injury should not be thought of as an “accident,” a term that implies a random circumstance resulting in harm. In fact, injuries occur in patterns that are predictable and preventable. The expression “an accident looking for a place to happen” is both paradoxical and premonitory. There are high-risk individuals and high-risk environments. In combination, they provide a chain of events that result in trauma. With the chang- ing perspective in today’s health care from managing illness to promoting wellness, injury prevention takes on the added dimension of not only promoting good health but also of reducing health care costs.

Prevention is timely. Doctors who care for the injured have a unique opportunity to practice effective, pre- ventive medicine. Although the true risk takers may be recalcitrant to any and all prevention messages, many persons injured through ignorance, carelessness, or temporary loss of self-control may be receptive to infor- mation likely to reduce their future vulnerability. Each doctor-patient encounter is an opportunity to reduce trauma recidivism. This is especially true for the surgeon who is involved daily during the acute postinjury period when there may be an opportunity to truly change behavior. The basic concepts of injury prevention are described and strategies for implementation through traditional public health methods are included in this appendix.




Prevention may be considered as primary, second- ary, or tertiary. Primary prevention refers to elimi- nation of the trauma incident totally so that it does not happen. Examples of primary prevention mea- sures include stoplights at intersections, window guards to prevent falls in toddlers, swimming pool fences to exclude nonswimmers from drowning, and medicine safety caps to prevent ingestions.

Secondary prevention accepts the fact that the injury may occur, but serves to reduce the severity of the injury sustained. Examples of secondary prevention include safety belts, motorcycle and bicycle helmets, and playground safety surfaces. Tertiary prevention means reducing the consequences of the injury after it has occurred. Trauma systems, including the coor- dination of emergency medical services, identifica- tion of trauma centers, and the integration of reha- bilitation services to reduce impairment, constitute efforts as tertiary prevention.


In the early 1970s, Haddon described a useful ap- proach to primary and secondary injury prevention that is now known as the Haddon Matrix. Accord- ing to Haddon’s conceptual framework, there are 3 principal factors in injury occurrence: (1) the injured person (host), (2) the injury mechanism (vehicle), and (3) the environment in which the injury occurs. There are 3 phases in which injury and its sever-

ity can be modified: (1) the preevent phase, (2) the event phase (injury), and (3) the postevent phase. Table 1, Haddon’s Factor-phase Matrix for Motor Vehicle Crash Prevention, characterizes how the matrix serves to identify opportunities for injury prevention and can be extrapolated to address other injury causes. The adoption of this structured design by the National Highway Traffic Safety Administra- tion (NHTSA) resulted in a sustained reduction in the fatality rate per vehicle mile driven over the past 2 decades.


Injury prevention can be directed to human factors (behavioral issues), vectors of injury, and/or envi- ronmental factors and implemented according to the four Es of injury prevention.

  • 1. Education

  • 2. Enforcement

  • 3. Engineering

  • 4. Economics (incentives)

Education is the cornerstone of injury prevention. Educational efforts are relatively easy to imple- ment, promote the development of constituencies, and also serve to bring the issue before the public. Without an informed and activist public, subse- quent legislative efforts (enforcement) are likely to fail. Education is based on the premise that knowl- edge supports a change in behavior. While attrac-

Table 1—Haddon’s Factor-phase Matrix for Motor Vehicle Crash Prevention






Avoid alcohol use

Use of safety belts

Bystander delivers care


Antilock brakes

Air bag deploys



Speed limits


Access to trauma system




tive in theory, education has been disappointing in practice. Yet it provides the underpinning for implementation of subsequent strategy to reduce al- cohol-related crash deaths. Mothers Against Drunk Driving (MADD) is an organization that exemplifies the effective use of a primary education strategy to reduce alcohol-related crash deaths. Through their efforts, an informed and aroused public facilitated the enactment of stricter drunk-driving laws, result- ing in a decade of reduced alcohol-related vehicle fa- talities. For education to work, it must be directed to the appropriate target group, it must be persistent, and it must be linked to other approaches.

Enforcement is a useful part of any effective injury prevention strategy because, regardless of the type of trauma, there always are those who resist changes needed to improve outcome, even if the improved outcome is their own. Where compliance with injury prevention efforts lags, legislation making certain behavior mandatory (or illegal) often results in dramatic differences. Safety belt laws resulted in measurable increases in usage where educational programs alone had minimal effect.

Engineering, often more expensive at first, clearly has the greatest long-term benefits. Despite proven effectiveness, engineering advances may require concomitant legislative and enforcement initiatives, enabling implementation on a larger scale. Adop- tion of air bags is a recent example of the application of advances in technology combined with features of enforcement. Other advances in highway design and safety have added tremendously to the margin of safety while driving.

Economic incentives, when used for the correct purpose, are quite effective. The linking of federal highway funds to the passage of motorcycle helmet laws motivated the states to pass such laws and enforce the wearing of helmets. This resulted in a 30% reduction in head injury fatalities. Although this economic incentive is no longer in effect and rates of head injury deaths have returned to their previous levels in states that have reversed their helmet statutes, the association between helmet laws and reduced fatalities confirmed the utility of economic incentives in injury prevention. Insurance companies have clear data on risk-taking behavior patterns, and the payments from insurance trusts, consequently, provide related discount premiums.


There are 5 basic steps to developing an injury pre- vention program.

  • A. Define the Problem

The first step is a basic one—define the problem. This may appear to be self-evident, but both the magnitude and community impact of trauma may be elusive unless reliable data are available. Popula- tion-based data on injury incidence are essential to identify the problem and to provide a baseline for determining the impact of subsequent efforts at in- jury prevention. Information from death certificates, hospital and/or emergency department discharge statistics, and trauma registry printouts are, col- lectively, good places to start. While community sentinel events may identify an individual trauma problem and raise public concern, high-profile prob- lems do not lend themselves to effective injury pre- vention unless they are part of a larger documented injury control issue.

  • B. Define Causes and Risk Factors

After a trauma problem is identified, causes and risk factors must be defined. The problem may need to be studied to determine what kind of injuries are involved and where, when, and why they are occurring. Injury prevention strategies may begin to emerge with this additional information. Some trauma problems may vary from community to community; however, there are certain risk factors that are likely to be constant across situations and across socioeconomic boundaries. Abuse of alcohol and other drugs is an example of a contributing factor that is likely to be pervasive regardless of whether the trauma is blunt or penetrating, the loca- tion is the inner city or the suburbs, fatalities alone or no injuries occur, and disabilities are included. Data are most meaningful when the injury problem is compared between populations with and without defined risk factors. In many instances, the injured persons may have multiple risk factors, and clearly defined populations may be difficult to sort out. In such cases, it is necessary to control for the con- founding variables.



  • C. Develop and Test Interventions

The next step is to develop and test interventions. This is the place for pilot programs to test interven- tion effectiveness. Rarely is an intervention likely to be picked up without some indication that it works. It is important to consider the views and values of the community if an injury prevention program is to be accepted. End points must be defined up front and outcomes reviewed without bias. It is some- times not possible to determine the effectiveness of a test program, especially if it is a small-scale trial intervention. For example, a public information pro- gram on safety belt use conducted at a school can be assessed by monitoring the incoming and outgoing school traffic and showing a difference, whereas the usage rates in the community as a whole may not change. Nonetheless, the implication is clear—broad implementation of public education regarding safety belt use can have a beneficial effect within a controlled community population. Telephone sur- veys are not reliable measures to confirm behavioral change, but they can confirm that the intervention reached the target group.

  • D. Implement Injury Prevention Strategies

With confirmation that a given intervention may effect favorable change, the next step is implementa- tion of injury prevention strategies. From this point, the possibilities are vast.

  • E. Evaluate Impact

With implementation comes the need to monitor the impact of the program or evaluation. An effective injury prevention program linked with an objective means to define its effectiveness can be a powerful message to the public, the press, and legislators, and ultimately may bring about a permanent change in behavior.



If this seems like a large task, in many ways it is. Yet, it is important to remember that a pediatrician in Tennessee was able to validate the need for infant safety seats that led to the first infant safety seat law. Another example is that of a New York orthopaedic surgeon whose testimony played an important role in achieving the first safety belt law in the United States. Although not all doctors are destined to make as big an impact, all doctors can have an im- pact on their patients’ behaviors. Injury prevention

measures do not have to be implemented on a grand scale to make a difference. Although doctors may not be able to prove a difference in their own patient population, if they all made injury prevention a part of their practice, the results could be significant. As preparations for hospital or emergency department discharge are being made, consideration should be given to patient education to prevent injury recur- rence. Whether it is alcohol abuse, returning to an unchanged hostile home environment, riding with- out head protection on a motorcycle, or smoking while refueling the car, there are many opportuni- ties for doctors to make a difference in their patients’ future trauma vulnerability.


  • 1. ACS Committee on Trauma: Injury prevention and control. Resources for Optimal Care of the Injured Patient. Chicago, in publication.

  • 2. Cooper A, Barlow B, Davidson L, et al: Epi- demiology of pediatric trauma: Importance of population-based statistics. Journal of Pediatric Surgery 1992; 27:149–154.

  • 3. Haddon W, Baker SP: Injury control. In: Clark DW, MacMahon B (eds): Prevention and Com- munity Medicine, 2nd Edition. Boston, Little Brown Co, 1981, pp 109–140.

  • 4. Laraque D, Barlow B: Prevention of pediatric injury. In: Ivatory R, Cayten G (eds): The Text- book of Penetrating Trauma, chapter 10. Balti- more, Williams & Wilkins, 1996.

  • 5. National Committee for Injury Prevention and Control: Injury Prevention: Meeting the Chal- lenge. New York, Education Development Cen- ter, 1989.

  • 6. Rivera FP: Traumatic deaths of children in United States: Currently available prevention strategies. Pediatrics 1985; 85:456–462.


  • 1. British Columbia Injury Research and Preven- tion Unit, Centre for Community Health and Health Research, L408-4480 Oak Street, Vancou- ver, BC V6H 3V4, Canada; 604/875-3776, www.

  • 2. Harborview Injury Prevention and Research Center, University of Washington, Box 359960, 325 Ninth Avenue, Seattle, WA 98104-2499; 206/ 521-1520,



  • 3. Harvard Injury Control Research Center, Har- vard School of Public Health, 677 Huntington Avenue, 2nd Floor, Boston, MA 02115; 617/432- 3420;

  • 4. Injury Control Research Center, Univer- sity of Alabama-Birmingham, CH19 UAB Sta- tion, Birmingham, AL 35294; 205/934-1643,

  • 5. Injury Prevention and Research Center, Uni- versity of North Carolina, 137 East Franklin St., CB#7505 CTP, Chapel Hill, NC 27599-7505; 919/966-2251,

  • 6. Injury Free Coalition for Kids, Columbia Uni- versity, Mailman School of Public Health, 722 West 168th Street, Rm 1711, New York, NY 10032; 212/342-0517;

  • 7. Iowa Injury Prevention Research Center, Uni- versity of Iowa, 158 IREH Oakdale Research Campus, Iowa City, IA 52242-5000; 319/335- 4458, www.pmeh.uiowa/iprc.

  • 8. Johns Hopkins Center for Injury Research and Policy, Hampton House, 624 N. Broadway, 5th Floor, Baltimore, MD 21205-1996; 410/614-4026,

  • 9. National Center for Injury Prevention and Con- trol, Centers for Disease Control, Program De- velopment and Implementation, Mailstop K65, 4770 Buford Highway NE, Atlanta, GA 30341- 3724; 770/488-1506,

    • 10. San Francisco Center for Injury Research and Prevention, San Francisco General Hospital, 1001 Potrero Avenue, Department of Surgery, Ward 3A, Box 0807, San Francisco, CA 94110; 415/206-4623,

    • 11. Slide Prevention Programs (Alcohol and Injury, Bicycle Helmet Safety), available from Ameri- can College of Surgeons, Customer Service/ Publications, 633 N. Saint Clair St., Chicago, IL 60611-3211; 312/202-5474; commerce/2003/trauma.html.

    • 12. Southern California Injury Prevention and Re- search Center, UCLA School of Public Health, 10911 Weyburn Avenue, Suite 200, Los Angeles, CA, 90024-2884; 310/794-2706, sciprc.

    • 13. State and Local Departments of Health, Injury Control Divisions.

    • 14. The Children’s Safety Network, National In- jury and Violence Prevention Resource Center, Education Development Center, Inc., 55 Chapel Street, Newton, MA 02458-1060; 617/969-7100,

    • 15. TIPP Sheets, available from American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, IL 60007; 800/433-9016,