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EDITORIALS: Ronald M Davis and Barry Pless BMJ bans "accidents" BMJ 2001; 322: 1320-1321 [Full text]

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Rapid Responses published:

The word 'accident' should not be purged

Judith M Green   (1 June 2001)

Accident looking for somewhere to happen

John McConnell   (1 June 2001)

First of June Fool?

Lucy-Jane Davis   (1 June 2001)

Newspeak

John Hopkins   (1 June 2001)

In defence of accidents.

Pat Coleman   (2 June 2001)

Re-consider ban on 'accident'

Nicholas Birkett   (2 June 2001)

Accidents are not deliberate.

C O Lister   (2 June 2001)

Not Evertone Agrees

Thomas H Taylor   (2 June 2001)

Join the real, less than perfect world!

Anthony Papagiannis   (2 June 2001)

Some daft terminology

Anna Whelan   (2 June 2001)

Re: right to a "t"

Nicholas Moore   (2 June 2001)

Don't be too hard on your editors

John Dutton   (2 June 2001)

Accident: Preventable; not Verboten

George Anstadt   (3 June 2001)

Accidents and Injuries - complementarity on prevention strategies

Mário Cordeiro   (4 June 2001)

Injevents?

Susan P Baker   (4 June 2001)

Accidental Hero or

Angela Thomson   (4 June 2001)

Re: Some daft terminology

Neville W Goodman   (5 June 2001)

Looking for Trouble

Stephen R Kepple   (5 June 2001)

Speculative philosophy and medicine

Sergio Stagnaro   (5 June 2001)

accidents happen

Tim Marshall   (5 June 2001)

Study accidents- reduce injuries.

Veronica Nanton   (5 June 2001)

More Descriptive Words

Doug Stephens   (5 June 2001)

injury and accident

Leon Robertson   (6 June 2001)

And if you still need more convincing look to Katmandu

Mark L Rosenberg   (6 June 2001)

Semantics and Reality

Joseph L Kearns   (6 June 2001)

Convince, don't ban

Hassan Soubhi   (6 June 2001)

"Accident" denotative and connotative meanings

Steven C Macdonald   (6 June 2001)

It was an accident

Kypros Kypri   (6 June 2001)

Assessing : Accident VS Injury

Les Fisher   (6 June 2001)

BMJ takes leadership role

Joan Ozanne-Smith   (6 June 2001)

The BMJ should also ban "Casualty"

Colin A Graham   (6 June 2001)

It's about time

Fred Rivara   (6 June 2001)

an accidental misleader?

David C Taylor   (6 June 2001)

Public health problem needs policy intervention

Tsung-Hsueh Lu   (7 June 2001)

Editorial: 'BMJ Bans Accidents'

S N Jarvis   (7 June 2001)

Don't take the "A" out of "A&E"!

Georgia Ingram   (7 June 2001)

The New Frontier: From Accidents to Near Misses and Adverse Events

Paul Barach, Julie Johnson Mohr   (8 June 2001)

Injuries not Accidents

Jo Sibert   (8 June 2001)

'Accidents' refer to what is not knowable

Craig Anderson   (8 June 2001)

Precise terms

Linda C Degutis   (8 June 2001)

Commonsense an accidental victim?

David C Anderson   (8 June 2001)

NLM's MeSH should be the next target

Tsung-Hsueh Lu   (8 June 2001)

Removing the comforts of the negligent majority

Douglas Carnall   (8 June 2001)

I admire your stance on this issue

Grier Bannon   (8 June 2001)

"accident" survivors

John Sery   (8 June 2001)

Precise terms lead to precise findings

Mary Overpeck   (9 June 2001)

BMJ bans "accidents"

Liz Iwanowski   (9 June 2001)

BMJ who?

Jim McKnight   (9 June 2001)

Accident is a kind word

Elaine Sugden   (11 June 2001)

Congratulations on taking a stand

Lou Romig   (11 June 2001)

Shall we Ban 'Non-Accidents' ?

Benjamin Jacobs   (12 June 2001)

WHAT'S IN A NAME?

Gordon Webster   (12 June 2001)

Reply to our readers

Ron Davis, Barry Pless   (12 June 2001)

Which accidents are preventable and which are not?

Ed van Beeck, Saakje Mulder   (12 June 2001)

Logic and language

Frank Haight   (15 June 2001)

Problem driving; an accident waiting to happen.

Laurence Jerome   (18 June 2001)

Accidentally on purpose

Stephen Due   (21 June 2001)

A Not So Splendid Isolation

Wim Rogmans   (21 June 2001)

The power of language

Jennifer Mindell   (21 June 2001)

Safety is not #1

Linda Long   (22 June 2001)

On indijents and injuries

Eleni Petridou   (22 June 2001)

Change is inevitable

Gary Kesling   (23 June 2001)

BMJ bans 'accidents'

John Heyworth   (26 June 2001)

The Word 'Accident'

Michael Cox   (28 June 2001)

Error is no accident

Andrew Lingwood, Nicholas Collins, Stephen Wilson   (28 June 2001)

Inevitability vs. Preventability

Leila M Hover   (30 June 2001)

How should we rename NAI?

Martin Wiese   (6 July 2001)

Imperial accidents and Injuries

John Lascaratos   (7 July 2001)

Re: The Word 'Accident'

Malcolm Klein   (17 July 2001)

Accidents of God

John Onorato   (29 August 2001)

The word 'accident' should not be purged 1 June 2001
Judith M Green, Senior Lecturer in Sociology London School of Hygiene & Tropical Medicine Send response to journal: Re: The word 'accident' should not be purged	To the Editor In their editorial, Davis and Pless[1] make a case for abandoning the word 'accident', on the grounds that accidents are understood to be unavoidable. At the level of population, most injuries are indeed predictable and preventable. At the individual level, in the 'real world' where injuries are suffered as misfortunes, they are not. The justification for purging the BMJ of the 'A' word is that the term is somehow contaminated with notions of unpredictability and therefore unavoidability. Since the middle of the twentieth century public health has referred to a lay public supposedly wedded to such fatalistic notions of unpredictable accidents [2]. This 'lay' view, professionals assert, is the major barrier to rational and effective injury reduction planning. The irrationality of the lay public, who need to be educated in the 'facts' of injury epideniology, is a seductive thesis, but sadly it has no basis in evidence. Detailed qualitative work [3] [4]has demonstrated that the 'lay' public largely share the understanding of public health professionals - that accidents are predictable, and ultimately preventable, at least in theory, and that luck has little part to play in the distribution of injury. They also understand the prevention paradox: that population level knowledge of the risk factors for accidental injury is of little help in explaining any specific individual event, except perhaps in retrospect. While supporting any move towards a more reliable and precise vocabulary for classifying injuries, I would suggest that attempts to separate medical writing from the 'real world' in which accidents are suffered is unlikely to achieve its goal of reducing the incidence and severity of injuries. As Davis and Pless suggest [1] there will still be moral and legal requirements to differentiate motivated from motiveless events, and to apportion blame where necessary for injury-producing incidents. Attempts to create a terminology with unecessary neologisms, unique to medical journals, is likely to alienate further those professionals who work with communities on accident prevention [5]. We already have a perfectly adequate generic term to cover the range of events which may injure people. It is 'accident', a term which has shifted in meaning considerably over time [4] to reflect changing medical and social understanding of risk and predictability. 'Accident' can serve medicine as well as it has served the English language. References [1]Davis R, Pless B. BMJ bans 'accidents'. BMJ 2001; 322:1320. [2] Green J.From accidents to risk: public health and preventable injury. Health, Risk and Society 1999;1: 25-39. [3] Roberts H, Smith S, Bryce C. Prevention is better... . Sociology of Health and Illness 1993;15: 447-63. [4] Green J. Risk and Misfotune: the social construction of accidents. London: UCL Press,1997. [5] Green J. Epistemology, evidence and experience:evidence based health care in the work of Accident Alliances. Sociology of Health and Illness 2000;22: 453-476
Accident looking for somewhere to happen 1 June 2001
John McConnell, Editor, The Lancet Infectious Diseases The Lancet, 84 Theobald's Road, London WC1X 8RR, UK Send response to journal: Re: Accident looking for somewhere to happen	My first reaction to attempts to replace simple words whose meaning is innate to all native English speakers with circumlocutory contrivances (“prostitute” with “commercial sex worker” springs to mind) is to reach for my dictionary. To quote from Chambers English Dictionary—7th ed (1989): “n. ac’cident that which happens: an unforeseen or unexpected event: a chance: a mishap: an unessential quality or property: unevenness of surface”. If your editors agree with these definitions, I suspect that they will seldom find cases where “use of the term is inappropriate or misleading” because your new stricture on the use of accident invoke the exact instrument of hindsight. For example, if a healthcare worker unintentionally sticks herself or himself with a contaminated needle, they might look back on the incident and think “although I now realise I ignored years of training and acted carelessly, I failed to foresee the event at the time”. That event is then clearly an accident by the dictionary definition. If on the other hand, a colleague had seen the healthcare worker handling the needle carelessly, immediately communicated their foresight, and the injury had still taken place, that is not an accident by the dictionary definition because the specific event was foreseen. Davis and Pless’ argument for doing away with accident is based on predictability—“However, most injuries and their precipitating events are predictable and preventable”. Yet they vitiate their own argument by citing earthquakes, lightning, storms, etc, as genuine accidents when we have entire professions dedicated to predicting these events with increasing accuracy. The point surely is not whether an event was theoretically predictable, but was it foreseen and expected by the direct participants? If not, it is by definition an accident. Before trying to do away with accident, I urge you to use the benefit of hindsight. Deliberate attempts to change the use of words have failed almost without exception, whereas constant actual changes in language are an accident of history.
First of June Fool? 1 June 2001
Lucy-Jane Davis, Study Administrator National Perinatal Epidemiology Unit Send response to journal: Re: First of June Fool?	I am surpised and disappointed at the suggestion of censoring the richness of the English language from your journal. Accidents do occur - and to remove this word from our vocabularly is to deny that sometimes no one is to blame when things go wrong. Some 'accidents' are the consequences of other people's actions, but the very word 'accidental' gives us the opportunity to accept that injuries may not be as a result of a deliberate plan to harm. Accidents will and do happen! I am hoping that this is some sort of elaborate hoax, staged in order to see how many responses you can get from your readers!
Newspeak 1 June 2001
John Hopkins, GP Darlington Send response to journal: Re: Newspeak	Dear Dr Smith, It is surprising the BMJ should associate itself with the somewhat Orwellian proposal that a particular word should be banned from use. Davis and Pless cite no evidence to suggest that by preventing " inappropriate" use of the word accident the world will become a safer place. It is arguable however that, in a small way, it will have become less liberal. Yours sincerely, Dr John Hopkins
In defence of accidents. 2 June 2001
Pat Coleman, Research Associate Medical Care Research Unit, ScHARR, University of Sheffield. Send response to journal: Re: In defence of accidents.	In defence of 'accidents' I understand fully the reasoning behind the decision of the BMJ to banish the word 'accidents'1 but am not persuaded that it is the right decision. How a problem is framed actually helps to shape the possibilities for its solution. Obviously, the health policy responses to prevent a poisoning injury that was not intended will be different from those to avoid the same injury outcome precipitated by an act intended to harm the self or others. To facilitate appropriate approaches to prevention, an injury needs to be understood broadly in the context of the 'perceived intent' of the precipitating events, and qualified as 'intentional' or 'unintentional' to inform prevention strategies. I would suggest that as the need for a qualification of 'intent' exists separately from associations about the degree of control attaching to the antecedent causes, and also the injury effect, this should not be lost. I would further suggest that as 'unintentional injury' by another name, is 'accident', the BMJ should offer clemency! 1 Editorial BMJ bans "accidents". 2001;322:1320-21.
Re-consider ban on 'accident' 2 June 2001
Nicholas Birkett, Associate Professor University of Ottawa Send response to journal: Re: Re-consider ban on 'accident'	Your ban on the word accident is just plain silly. If there is a scientific or medical justification to replace the word in some specific contexts then fine, replace it. But to impose a blanket ban on a common English word is simply censorship for no reason. The implication behind the ban is that nothing happens by chance: we can always find a reason to blame for a bad event. This is a political, not a scientific statement. It is also wrong, as shown by your own examples of earthquakes or hurricanes. For a less dramatic example, if I play soccer and twist my ankle trying to kick the ball when no other players are around, I have been injured but it also was an accident. I have no one else to blame. To try and blame the groundskeeper is silly. To say I shouldn't have been playing is even sillier. Your position caters to the view that we should eliminate all risk from our lives. THis is not only impossible but also not desirable. Please re-consider this decision.
Accidents are not deliberate. 2 June 2001
C O Lister, Retired Send response to journal: Re: Accidents are not deliberate.	May I suggest that the essence of an accident is that the happening is not deliberate. It may be that accidents are due to human failings, or to a mixture of human failing and an unlikely or unforseeable event/s. The fact that a happening is termed an accident does not infer that no one is blameworthy, but merely that it has not been deliberately contrived. May I suggest further that the explanation set out above is well understood by most people and that the decision to avoid the use of the word "accident" is yet another example of unnecessary "political correctness", one of the nastiest afflictions of our time
Not Evertone Agrees 2 June 2001
Thomas H Taylor, Senior Statistician, Epidemiology Division University of California, Irvine Send response to journal: Re: Not Evertone Agrees	For me, the word 'accident' does not connote 'unpredictable,' and never has. Rather, the word 'accident' connotes 'unintentional.' Because I do not equate 'accidental' with 'unpredictable' or 'at random,' then this is all much ado about nothing for me and, I suspect, many others.
Join the real, less than perfect world! 2 June 2001
Anthony Papagiannis, Respiratory Physician Thessaloniki, Greece Send response to journal: Re: Join the real, less than perfect world!	In a perfect world 'accidents' would not happen, and the very word would be incomprehensible. However, in medicine as well as in everyday life we have to deal with imperfect human beings, fallible machines and situations that defy prognosis and forward planning. I agree that some accidents are more predictable, and therefore more preventable, than others. Our aim should be to identify and eliminate those that fit the bill. However, if we promote an image of infallibility and aim to appoint blame for any happenstance, then the expectations of the public (and the lawyers that frequently represent it) would grow inordinately high, to everybody's detriment. Now that would not be an accident!
Some daft terminology 2 June 2001
Anna Whelan, Corporate Services Officer Orkney Islands Council Send response to journal: Re: Some daft terminology	Attempts to substitute politically correct words for those in common parlance can lead to some daft terminology. One local newspaper in South West London persistently refers to pedestrian casualties as having been "in collision" with vehicles, suggesting a rather more equal contest than that experienced by the pedestrian, who would probably say that he or she has been knocked down or run over - if still in a position to comment at all. With hindsight, the pedestrian might agree that it was not a good idea to cross the road without looking, but he or she has probably done the same thing on many previous occasions without mishap. Statistically, there may have been the same probability of meeting a car each time, but humans do not conduct a Bayesian analysis every time they cross the road. After crossing the Cromwell Road twice a day for ten years I felt that a close encounter with a No. 74 bus was becoming a near certainty. Having now moved to Orkney, getting mown down by one would qualify as an achievement rather than an accident.
Re: right to a "t" 2 June 2001
Nicholas Moore, Prof clinical pharmacology Univ Bordeaux2 Send response to journal: Re: Re: right to a "t"	as an example, would the typing of a "t" rather than a "y" in "not evertone agrees" qualify as an accident, an incident, a mishap, a slip of the finger, a deliberate provocation, the result of the poor layout of the common keyboard, or oversight during proofreading, or a combination of the above? In my realm of adverse drug reactions, type A (pharmacologically related, usually preventable or anticipated) reactions would not qualify as accidents. Type B reactions, such as toxic epidermal necrolysis (Lyell syndrome) could however qualify: even if a drug is associated with increased risk of such a reaction, its occurrence in a given patient taking that drug can usually not be predicted or anticipated. Accidents do happen, even though we strive to prevent, avoid or mitigate them. Have a nice, accident-free weekend.
Don't be too hard on your editors 2 June 2001
John Dutton, GP Principal Send response to journal: Re: Don't be too hard on your editors	You are asking your editors to "be vigilant in detecting and rejecting inappropriate use of the 'A' word", but please don't come down too hard on them if they fail and the word slips through onto your pages. We your readers recognise that these these things happen even in the best regulated circles. We will realise that it was just an accident.
Accident: Preventable; not Verboten 3 June 2001
George Anstadt, Medical Director Lucid, Inc. Send response to journal: Re: Accident: Preventable; not Verboten	Two conditions, low probability and lack of awareness, are comingled into the perfectly respectable English word "accident"; it is a useful word, and is commonly employed because coincidence of these two conditions so often causes trouble. My Webster's Unabridged makes no hint that accidents are without cause, or cannot be prevented. Of course, both intentional (e.g. homocide) and unintentional(e.g. accidental automobile crashes) injuries can be prevented. Using the tools of modern prevention science, very often this can be done cost effectively. These latter situations are the worthwhile focus for the BMJ editorial staff when reviewing papers that deal with injury.
Accidents and Injuries - complementarity on prevention strategies 4 June 2001
Mário Cordeiro, Proefssor of Pediatrics and Public Health Faculty of Medical Sciences of Lisboa Send response to journal: Re: Accidents and Injuries - complementarity on prevention strategies	Dear Sir I have been reading the editorial of the BMJ "banning" the word accident, and the following comments. Being the National Manager of the former EHLASS programme and the representant of Portugal in the EU Comitttee for "Lesion prevention", I agree that the word accident has been too much used and that, especially in our southern European countries, may lead to the "fatalistic" idea that "nothing can be done". However, in terms of physiopathology, I think that one thing is the event, which we can anticipate in terms of risk of occurrence but not estimate the exact moment of occurrence - and that is the accident: I have a wire on the floor, I can anticipate that someone may fall by steping on it, but don´t know the exact moment - and some are preventable (like this example) some may not (if a driver has a sudden heart attack and the car crushes). The other thing is the consequence of the accident, determined by the energy that is released by the accident and how the environment and the elements present (like the humans) deal with it (back to Hugh de Haven and Haddon...). I may step in the wire, fall and nothing happens or my head may hit a marble surface and I develop head trauma. The driver has a heart attack and as I am wearing seatbelt I do not have problems when the car crushes, or I may not wear it and I can be killed by the accident). So, the word should not be banned - just say that it should be send to its proper place and meaning. Obviously, what we must say is that we have to avoid injuries, either by preventing accidents or by preventing their consequences. Mário Cordeiro Professor of Paediatrics and Public Health Director - National Observatory for Health Tv. Pote de Água - 10 - 8º 1700-317 LISBOA
Injevents? 4 June 2001
Susan P Baker, Professor Johns Hopkins School of Public Health Send response to journal: Re: Injevents?	Congratulations to BMJ for this bold step. The trick will be to develop a commonly accepted substitute. (Injevents?) Whatever the choice, be prepared for a long wait for general recognition! Authors will need to be wary about indexing. When I wrote my first textbook chapter, I called it "Injury Control" and used the A-word only once, to explain why I was not using it. When the textbook was published in 1973, anyone looking in the index for 'accidents' (which is where 95% of readers would have looked for the topic) were led only to another chapter in which childhood 'accidents' were described.
Accidental Hero or 4 June 2001
Angela Thomson, Queensland Injury Prevention Representative (Public Health Association of Australia) Queensland University of Technology, Brisbane, Australia. Send response to journal: Re: Accidental Hero or	Is it by accident that the BMJ decided to ban the word accident or could this have been predicted? Some may argue that accidents are predictive and preventable and others may argue that they are not. However, of greatest concern is the labelling of victims of accidents. What word could possibly describe the distressing situation in which people are victims of factors that can not be prevented nor predicted by them? If accident victims could predict and prevent the injuries & disabilities sustained to them, wouldn't they have reduced the risk factors involved? Banning the word accident is not going to change the injury morbidity and mortality statistics that exist and are predicted by researchers worlwide. What's in a word?
Re: Some daft terminology 5 June 2001
Neville W Goodman, Consultant Anaesthetist Southmead Hospital Send response to journal: Re: Re: Some daft terminology	The reason for not writing "Mr Bloggs was hit by a car",and instead writing that he was "in collision", is not linguistic but legal. A driver could claim that he or she was being blamed by the first description, but not by the second. On the more general point of what to do with 'accident': banning it is just plain daft; but it makes sense to replace 'accident' by a more precise phrase whenever appropriate.
Looking for Trouble 5 June 2001
Stephen R Kepple, Copy-Editing Manager American Society of Health-System Pharmacists Send response to journal: Re: Looking for Trouble	Overall, I find the distinction BMJ is trying to make hairsplitting and impractical. Most will have great difficulty comprehending the point of it all or knowing which word to use when. Journal editors across the world will have to ask, Do we really want to visit this artificial issue upon ourselves and our authors? To me, accidents may be predictable and preventable or not, as the case may be. I think of an accident as some event that is not desirable but that happened anyway, with or without efforts to avoid it. When there is conscious intention preceding an event, however, that event is not an accident. How many people, other than arrant criminals, intend to crash their car or administer the wrong drug? Unless there is planning and intent, these are accidents and will always remain so in the lexicon. I think we should be sensitive to the use of "accident" as a euphemism and should intervene in selected instances. But, as a long-time editor, I've found that attempts to ban useful words that are deeply engrained in the vocabulary almost always cause more problems than they solve. I hope that the editors of BMJ will be open-minded and courageous enough to reconsider their decision.
Speculative philosophy and medicine 5 June 2001
Sergio Stagnaro, Specialist in Blood, Metabolic and Gastrointestinal Diseases. Riva Trigoso (Genoa) Italy Send response to journal: Re: Speculative philosophy and medicine	Sirs, I am sorry to find out that unfortunately too often all over the world there is a distressing lack of "original" ideas, theories, conjectures and so on, even in Medicine, which results in philosophically useless dicussions. This article shows clearly that a lot of people are still nowadays slaves to words, according to K. Popper, and consequently spend precious time devoting themselves to speculative philosophy, as in this paper. As a matter of fact, according to chaos theory, we don't know and we never shall know exactly the so-called initial conditions so that we apparently see "chaos" where really exists a superior order. In my opinion, the most important point is to agree about a word's real significance rather than the word "sound" or "writing". In addition, there are numerous other topics to be discussed in the interest of both health and diseased people: for instance, in what way do healthy people become slowly diseased? More precisely, when and how do healthy people become "diabetic" patients(NIDDM)? (1, 2) Yours, Stagnaro Sergio MD, Member Nyas and AAAS Riva Trigoso (Genoa) Italy 1) Stagnaro S., Stagnaro-Neri M. Valutazione percusso-ascoltatoria del Diabete Mellito. Aspetti teorici e pratici. Epat. 32, 131 1986 2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: valutazione clinica del picco precoce della secrezione insulinica di base e dopo stimolazione tiroidea, surrenalica, con glucagone endogeno e dopo attivazione del sistema renina-angiotesina circolante e tessutale – Acta Med. Medit. 13, 99 1997
accidents happen 5 June 2001
Tim Marshall, senior lecturer university of birmingham Send response to journal: Re: accidents happen	15-20 years ago a book called "Accidents Happen" included on the first page the following arresting sentence: "A submarine has collided with a bicycle, a yachtsman has had his bowsprit cut off by a railway train, and an aircraft has taken off towing a glider with neither craft having anyone on board." There is no hope for anyone not attracted by such extraordinary happenings, though all of them contained elements of thoughtlessness, ignorance, stupidity etc. which could (relatively) easily have been avoided. But how should we characterise the event where a bee landed on someone's snorkel, he breathed in, was stung in the mouth, and died? With hindsight we know that putting a mesh across the top of the snorkel would have stoppped this, but hindsight is a wondrous thing not given to most of us in advance. Perhaps an accident could be described as something we haven't seen how to prevent, before it happens, but afterwards any repetition can be attributed to ignorance, carlessness etc.
Study accidents- reduce injuries. 5 June 2001
Veronica Nanton, Continuing student, University of Birmingham National Institute of Conductive Education Send response to journal: Re: Study accidents- reduce injuries.	The proposed ban on the use of the word accident is at best unnecessary and at worst undesirable. The sole reason given for this extreme measure is an alleged connotation of unavoidability.This is perhaps more real in the minds of the authors than in the minds of the majority of the general population.Unavoidability is a concept linked to those of fatalism and irresponsibility which have surfaced sporadically in the literature since the 1930s.(1)These are assumed attitudes of parents who appear to ignore health promotion messages on safety education. Evidence suggests however, that parents have realistic views ,based on experience, regarding the difficulty of avoiding accidents in unsafe surroundings.The behaviour of parents,in terms of preventative effort however, does not reflect attitudes of fatalism, irresponsibility or unavoidability.Families in which high levels of accidents occur are as aware as others of the possibility of prevention (2,3) The dangers of replacing the term accident are twofold. Firstly, the sole use of 'injury' risks narrowing the focus of concern to the physical damage resulting from an accident and thereby marginalising the possible range of sequelae.Secondly it ignores lessons which should be learnt from examining the 'near miss'(2)Circumstances, chains of events which either led to an injury or where an injury has been avoided are important areas of investigation. Accident research is a broad field involving a range of disciplines.Injury prevention is its aim. References. 1 Safety First;1932 7:60 London 2 Roberts H,Smith S,Bryce C.Children at Risk? Safety As A Social Value.1995 OUP Buckingham 3 Nanton V.1998 2005:Why Some Children Will Continue To, Have More Accidents. Progress in Community Child Health vol 2.Spencer N (ed)Churchill Livingstone London
More Descriptive Words 5 June 2001
Doug Stephens Nashville, TN USA Send response to journal: Re: More Descriptive Words	I am in favor of eliminating the word "accident" from our culture with the condition that the word we replace it with be more descriptive of what is really going on in the workplace. When an "accident" occurs that causes a fatality, our investigations usually show that there were other similar incidents which preceded the fatality. These incidents were usually in the form of near misses or retalitively slight injuries, but could have led to prevention of the fatality if they had been properly investigated and fixes made. In cases like these we miss a chance to predict an outcome by not listening to a workplace that is screaming at us, telling us that there is a problem. So we ignore it until someone is killed. We should not call this an accident. We should call it what it really is. My suggestion-- corpricide. May I also suggest a word for those "accidents" that are not fatal but serious injuries occur--corprassault.
injury and accident 6 June 2001
Leon Robertson, retired Yale epidemiologist Send response to journal: Re: injury and accident	In addition to your excellent rationale for dropping "accident" is the ambiguity of the term. It covers everything from spilled milk to death. Good science demands more precise terminology regarding injury.
And if you still need more convincing look to Katmandu 6 June 2001
Mark L Rosenberg, The Task Force for Child Survival and Development Decatur, GA, USA Send response to journal: Re: And if you still need more convincing look to Katmandu	Banning the incorrect use of the word "accident" is one more outstanding move by one outstanding journal. The incorrect use of the word causes more harm than good. The ultimate rejection of the word occurred this week in Katmandu when the Nepalese palace spokesperson announced that the royal family--who had been mowed down by gunfire from a semi-automatic gun and then systematically shot through the head to finish them off--had died from an "accident." The Nepalese people then rioted in the streets. Can't we do better than that? It's about time.
Semantics and Reality 6 June 2001
Joseph L Kearns, Retired Occupational Physician Send response to journal: Re: Semantics and Reality	The first paragraph of the Editorial encapsulates an understanding of "accidents" achieved decades ago in health and safety literature. In real life, it is even more important for doctors to discard the euphemistic concept of the "untoward event". Semantic rigour and analysis must identify not only clinical facts, but also the other "factors affecting clinical judgement, performance and outcome" recognised in GMC News, Summer, 1998,reporting upon issues arising from the Bristol case. Published analysis of, and reaction to injury or dangerous occurrence is fundamental to the prevention of repetition. Only implementation elsewhere will really reduce the events described as "accidents" which will otherwise be reported in thousands more papers written in the next five years. Deaths and injuries inflicted on patients in our care, described in Reports by the National Audit Office,("Health and Safety in NHS Acute Hospitals in England and Wales", November 1996; "The Management and Control of Hospital Acquired Infection in Acute Hospitals in England", February 2000) are due in part to defective premises, plant and equipment, to fatigue, to insufficient staff and to unsafe systems of work. The Editorial challenges the sadly still vernacular assumption that "accidents" are not predictable, and the implication that "untoward events" are even less so when living organisms are manipulated. Surely, some radical intelligent action is imperative, even if the ban on a word is impractical. Joseph L Kearns, Retired Occupational Physician. Interest: Years of membership of BMA Occupational Health Committee.
Convince, don't ban 6 June 2001
Hassan Soubhi, Post-Doctoral Fellow University of British Columbia Send response to journal: Re: Convince, don't ban	I think that addressing injury control using linguistics and rhetorical arguments is not efficient and can be misleading. Our efforts should not be invested in word quibbles. If injury control is set as a priority for both rigorous research and successful implementation, then there will be no need to ban or promote any specific word. The results will speak for themselves.
"Accident" denotative and connotative meanings 6 June 2001
Steven C Macdonald, Senior Epidemiologist Washington State Department of Health Send response to journal: Re: "Accident" denotative and connotative meanings	The term "accident" is imprecise and often misleading, and BMJ editors are to be applauded for their decision. Its imprecision comes from its denotative meaning: is the writer referring to the event, the injury, or the precursors? That the term can be misleading is well explained in the editorial. I look forward to the day when "accident" is simply viewed as archaic.
It was an accident 6 June 2001
Kypros Kypri, Health Research Council Postgraduate Scholar Injury Prevention Research Unit Send response to journal: Re: It was an accident	BMJ's decision to ban the word "accident" from its pages is laudable. Despite a preponderance of scientific evidence showing lawful relationships between injury events and a variety of environmental, social and individual factors, policy makers and the wider public remain inclined to dismiss preventable trauma as the result of forces beyond their control. By setting a standard, the scientific community builds on its significant achievements in injury prevention. Lets hope other journals follow rise to the BMJ's standard. Kyp Kypri Injury Prevention Research Unit, University of Otago, Dunedin, New Zealand
Assessing : Accident VS Injury 6 June 2001
Les Fisher, Manager ? Safety Consultant Delmar, NY , USA. Send response to journal: Re: Assessing : Accident VS Injury	Kudos to Drs. Davis and Pless on their Editorial : BMJ Bans Accidents. As a forty year seasoned injury control practitioner, historian and archivist, I offer this background: In 1788, Johann Frank, the father of many public health programs, named " accident " prevention, but as an ugly duckling. Frank said " this too shall be a public health program because " injury is a grevious scourge on the land ". As many other medical and health professionals, to follow, Frank believed in several basic premises and myths that : injuries resulted from ONLY human mini- interactions, from fate, and could ONLY be prevented by human control of carelessness or safety for preventing the "accident". The people " accident ", is believed the main focus for any prevention; and blame ( due to police conducting such investigations, historically )is essential. While most public health programs and ideas - on miasmas causing disease to locking up imbeciles in asylums - grew into adulthood , as they all were given a sharing of the three necesssary attributes of primary , secondary and tertiary prevention; accident prevention development remained archaic until some thirty years ago, with new responsible engineering, medical and public health injury control leadership. "Accident" , today, as in Frank's time, remains an inappropriate myth of randomness, in truth, as for disease it is individual and population interactions with sources of energy ( for disease, it's biological energy ) gone- wrong episodes. The frequency and severity of injury events is controllable. And so are the result of human exposure to and use of sources of physical energy in which the prevention of undesireable energy transfers ( so called accidents) depends BOTH on the adequate level of human performance and on a task that is not too demanding. As with any other scientific discipline's terms , concepts and myths must be updated. And why should injury remain different? The acceptance of "accident" probably has led to cars unsafe at any speed or user action, flammable sleepwear burns to toddlers, and poisoning deaths from asprin bottles - all associated with thousands of unneccesary injuries. And how many tomorrow from accident terminology being used by professionals? Congratulations Drs. Pless and Davis; your medical and public health leadership should be imitated. ( Above based, in part, on : Waller, Julian. Editorial: The accident, the ugly duckling, and the three preventions: a fable for mature health officers. American Journal of Public health, April 1974 )
BMJ takes leadership role 6 June 2001
Joan Ozanne-Smith, Chair of Injury Prevention Monash University Send response to journal: Re: BMJ takes leadership role	Congratulations to the BMJ for taking a strong, though overdue, stance on an important public health issue by recognising in your editorial policy that injuries are not "accidents". It was common practice in the nineteenth century for an infectious disease outbreak to be described as an "act of God". One wonders when and by whom editorial policy was changed on that issue? In most instances alternative words exist to replace "accident". Perhaps, rather than coining a new word for those instances where the English language fails us, we should explore the many other existing languages for a word with the required meaning and adopt it into English.
The BMJ should also ban "Casualty" 6 June 2001
Colin A Graham, Specialist Registrar in Accident & Emergency Medicine Victoria Infirmary, Langside Road, Glasgow. G42 9TY. Send response to journal: Re: The BMJ should also ban "Casualty"	There is another word that needs to be banned by the BMJ - "Casualty". I have now read this term twice in the last two weeks in the BMJ (Minerva this week and Lam et al, BMJ 2001;322:1288-9) despite Platt recommending in 1961 that this term for the emergency receiving facility of a hospital be replaced with the term "Accident & Emergency Department". It is sad to see that one of UK's most foremost medical journals continues to utilise this term in the 21st century and continue to refer to specialists in accident and emergency medicine as "casualty staff". Any chance of an immediate ban on "Casualty"?
It's about time 6 June 2001
Fred Rivara, Professor Harborview Injury Prevention and Research Center, Seattle, WA USA Send response to journal: Re: It's about time	The editorial by Davis and Pless is long overdue. For too many years, one of the greatest deterrents to injury prevention was the sense of fatalism which people have had about "accidents." This fatalism arises from a desire to blame the victim, for being drunk or a bad parent or poor or irresponsible. This accomplished nothing positive and a lot negative, by diverting attention away from actions which could do something to prevent injuries. The use of the term injury rather than accident focuses attention on the damage to the person and what can be done to prevent this damage. Thanks Drs. Davis and Pless for bringing another journal up to date. Fred Rivara
an accidental misleader? 6 June 2001
David C Taylor, Visiting Professor Dept of Neurology Great Ormond St Hospital Send response to journal: Re: an accidental misleader?	Dear Sir, I taught my students that I would accept as an accident, the misfortune of being struck while walking lost and alone across the Scottish moors, by part of the frozen jettison from an off course jumbo jet. Unlike Davis and Pless, I was drawing attention to “That which is present by chance, and therefore non-essential.” (see OED under II). I agree that a number of tragedies prove, on analysis, to have been entirely predictable. What makes an accident just that is the size of the part played by the Goddess Fortuna. She is the controller of destinies, but she is depicted standing on a ball. To nod off at the wheel at the end of a long shift on a freezing night is one thing. To have it happen that a darkly clad group of cadets are marching on the road in the gloom ahead is quite another. Your article offends because it contributes further to the culture of blame. You fail to notice that accidents are usually predictable retrospectively by detached and uninvolved observers separated from just those chance contingencies that set up that one tragedy that drew attention to the problem. It offends because it seeks to proscribe a word, to censor, in order to achieve an effect. It offends because that is a dangerous and totalitarian policy. The word you are looking for is not “injident” but indigent; OED 1a “Lacking in what is requisite, falling short of the proper measure or standard; wanting, deficient”. Caveat the BMJ. David Taylor M.D., MSc., F.R.C.P., F.R.C.Psych., Hon F.R.C.P.C.H. GWENT NP7 9EW
Public health problem needs policy intervention 7 June 2001
Tsung-Hsueh Lu, Senior Lecturer Department of Public Health, Chung Shan Medical & Dental College, Taichung, TAIWAN Send response to journal: Re: Public health problem needs policy intervention	Injury is a serious public health problem which needs effective policy intervention. Changing the editorial policy is an important upstream advocacy influencing the production of relevant knowledge for practice. We appreciate BMJ's new editorial policy on banning the use of "accident" which reflected the accumulated knowledge in injury prevention and control. Potential authors and readers of BMJ could be an important target group for behaviour modification in their recognition of this public health problem.
Editorial: 'BMJ Bans Accidents' 7 June 2001
S N Jarvis, Donald Court Professor of Community Child Health University of Newcastle Send response to journal: Re: Editorial: 'BMJ Bans Accidents'	I congratulate Ronald Davis and Barry Pless on this Editorial. Even when injuries are unintentional there are usually obvious and avoidable causes. We cannot afford to dismiss injuries as 'accidents' when they are the current cause of death in our children and young people. Most injuries are no more accidental than poliomyelitis, and a good deal commoner.
Don't take the "A" out of "A&E"! 7 June 2001
Georgia Ingram, SHO in Accident and Emergency Medicine Bradford Royal Infirmary Send response to journal: Re: Don't take the "A" out of "A&E"!	EDITOR- How can the BMJ decide to ban the use of "accidents" within its hallowed pages? (ref.1) The editorial authors state that "correct and consistent terminology will improve understanding" of injury patterns and aid prevention. I would argue that it is for precisely this reason that we should keep the word "accident" within the medical nomenclature. Defined simply, an accident is an adverse event that was not intended by any party to occur. Thus a five-year old child who trips over and scrapes a knee has had an accident. So has the driver who hits the kerb and loses control of his vehicle. Note that the definition does allow causative factors to be considered. If the child had better balance, or the driver was not tired, these accidents may not have occurred. Yet the fact remains that both events were not intentioned, and both resulted in adverse outcomes, therefore were accidental. Another advantage of retaining the concept of accident is that it does not attribute automatic fault. In the ever-increasing litagenous atmosphere of the United Kingdom I feel that the banning of the concept of accident is politically correct extremism, which can only serve to encourage the "blame culture". Lastly, an accident survivor (ref.1) is in my opinion simply that; a person who has been involved in a severe unintentioned event who is still alive. Or would the BMJ prefer that they be referred to as S.A.F.E. (Still Alive Following Accident) ? Dr G. Ingram Competing interests; None
The New Frontier: From Accidents to Near Misses and Adverse Events 8 June 2001
Paul Barach, Co-director Center for Patient Safety; Center for Education and Research on Therapeutics University of Chicago; University of North Carolina School of Pharmacy, Julie Johnson Mohr Send response to journal: Re: The New Frontier: From Accidents to Near Misses and Adverse Events	We would like to congratulate the BMJ for taking the long overdue step to ban the use of the term “accidents” (1). For human error, patient safety, and quality improvement to become more rigorous fields of inquiry, it is time that we come to agreement on the nomenclature (2). During the past few decades, injury control has emerged as a distinct discipline within public health. A key tenet of injury control is that injuries are not accidents that are random, uncontrollable acts of fate; rather, most injuries are predictable and preventable. One of the many parallels between injury control, and patient safety, is that most medical adverse events are predictable and preventable. The evolution in thought about adverse events is reflected in their classification. Patient adverse events often are classified as accidental or intentional. The word “accident” encompasses a very large and fuzzy set of events. To some, accidents are random events that are unforeseen, unfortunate, and unexpected. The term is intertwined with the notion that some human error or behavior is responsible for most adverse events (3). This focus of attention on the human actors involved tends to detract from an examination of the full range of systemic factors that contribute to near misses and adverse events, such as clumsy technology, poor ergonomics, and the lack of communication and teamwork. There is a long tradition in medicine of carefully examining past practice to understand how things might have been done differently, and thus improved in the future. Although the word accident had various meanings historically, it is now primarily a euphemism for lack of intent or unpreventable occurrence, as though intent were a primary consideration in injury prevention (3). However, most incident analyses in healthcare share the same shortcomings: lack of human factors and systems thinking; a narrow focus on individuals and performance judged in hindsight as errors; and lack of multidisciplinary integration into an organization-wide safety culture. An organization’s interpretation of adverse events and near misses influences how it collects safety related process information in general, and thus its capacity to prevent undesirable occurrences from recurring. We assembled definitions from the non-medical incident reporting literature of the most common terms used to describe unexpected and undesirable adverse events (4). These functional definitions included errors, unsafe actions, near miss, incident, critical incident, and accidents. We found that the definitions used to classify clinical events influence the effectiveness of the incident reporting system. Incident reporting systems in non-medical domains have evolved over the past three decades from a focus on accidents, to incidents and near misses, and from linear root cause analysis to nonlinear multiple causation. A continuum exists from unsafe acts and minor incidents, to near misses and full blown adverse events. Consequently, the same set of failure causes and their relationships precede both adverse events and near misses. Only the presence or absence of recovery mechanisms determines the actual outcome. By definition, analysis of near misses emphasizes the recovery processes, which thereby interrupts the progression of events to an adverse outcome (5). Developing a framework for defining and teaching recovery strategies supports changing the culture of blame that hampers constructive incident reporting. Finally, near misses provide a powerful reminder of the hazards confronting the system and slow down the process of forgetting to be afraid. Patient safety research and guidelines will gain wider acceptance in healthcare, when we break our misleading and disinformation campaign of accident control and ban the “A” word. It is time to agree to a shared language that more accurately describes adverse events and near misses, and helps identify the changes that are required at the micro-system level to transform the safety of patient care (6). Paul Barach, MD, MPH Center for Patient Safety, Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637 Julie J. Mohr, MSPH, PhD Center for Education and Research on Therapeutics, The University of North Carolina School of Pharmacy, CB#7360, Beard Hall, Chapel Hill, NC 27599-7360 References 1.Davis R, Pless B. BMJ bans ‘accidents’. BMJ 2001’322:1320. 2.To Err is Human: Building a Safety Health System, Institute of Medicine report, National Academy Press,1999. 3.Robertson L. Injury epidemeology, 2nd edition, Oxford;Oxford University Press, 1998. 4.Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ 2000;320:753- 763. 5.Van der Schaff TW. Development of a near miss management system at a chemical process plant In: Near Miss Reporting as a Safety Tool. Van der Schaff TW, Hale AR, Lucas DA, (eds.), Oxford; Butterworth and Heinemann, 1991. 6.Donaldson, M.S. and Mohr, J.J. Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross Case Analysis. A Technical Report for the Institute of Medicine Committee on the Quality of Health Care in America. Robert Wood Johnson Foundation Grant Number 36222. Princeton, NJ: 2000. The authors declare no competing interests.
Injuries not Accidents 8 June 2001
Jo Sibert, Professor of Community Child Health, University of Wales College of Medicine Llandough Hospital, Penarth, Wales CF64 2XX Send response to journal: Re: Injuries not Accidents	I welcomed your editorial, using the word injury helps us focus on the actual epidemiology, the people most at risk and what can be done to prevent these episodes. Using the word accident implies that they occur randomly throughout the population, which they clearly do not. For instance a child in the poorest home has a 20 times greater chance of dying from a house fire than the richest. His or her death is not an accident: it is the consequence of the child’s environment. An environment that should not have been to allowed to exist without a working smoke alarm. Using the word accident lets the authorities off the hook and gives them an excuse for inaction.
'Accidents' refer to what is not knowable 8 June 2001
Craig Anderson, Epidemiologist University of California, Irvine Send response to journal: Re: 'Accidents' refer to what is not knowable	To refer to injuries as accidents is to divert one's attention from what is knowable--a sequence of events and their medical consequences--to what is not difficult to know and rarely assessed--the contents of someone's mind.
Precise terms 8 June 2001
Linda C Degutis, Associate Professor Yale University Send response to journal: Re: Precise terms	Congratulations to BMJ for taking this step forward. There are more precise terms that can be used to replace the term "accident". As it doesn't apply to all injury events, it seems that the struggle to find a single term that describes both unintentional and intentional incidents or acts that lead to injury may not be necessary. We don't struggle to find one term that describes all causes of heart disease, or cancer, so why is it necessary to do so for injury?
Commonsense an accidental victim? 8 June 2001
David C Anderson, Private Physician and Endocrinologist Hong Kong Send response to journal: Re: Commonsense an accidental victim?	To The Editor I am afraid I disagree completely with Davis and Pless' proposal to censor the word 'accident' from the BMJ. Many words in the English language have more than one meaning, and I am sure that most people do not find the words 'accident' and 'preventible'/'avoidable' to be mutually exclusive. Those of us that live in the real world realise that accidents do happen, and always will. Injuries to third parties are generally understood to be accidental if it is not the deliberate intention of the person primarily responsible. Thus, in my book it is not an accident if I am machine-gunned by a terrorist out to kill doctors or innocent bystanders; but it is if I am hit by a bus, whether due to my carelessness, the driver's, a brake failure, or a lightning strike. In either case it is fortuitous ('an accident of fate'?) that it is me that is at the receiving end and not someone else. The premise that because accidents are unpredictable they are therefore unavoidable is patent nonsense, and actually runs counter to the mainstream philosophy of accident prediction (such as exploring and learning from critical incidents). So would the BMJ please stop meddling with a perfectly good word, which does not necessarily imply anything about whether it can be prevented or not?! I find it no more a contradiction to say that accidents are preventible, than that war, suicide, tuberculosis or murder are; although they will never be totally eliminated! David Anderson Hong Kong
NLM's MeSH should be the next target 8 June 2001
Tsung-Hsueh Lu, Senior Lecturer Department of Public Health, Chung Shan Medical & Dental College Send response to journal: Re: NLM's MeSH should be the next target	Why do authors keep on using "accident"? Because this is still an official key word used by United States National Library of Medicine (NLM). Authors of published articles certainly hope that their works have been read and used by other researchers or for practical implications. People usually will or have to search the relevant articles through the electronic health information resources, e.g., MEDLINE. Medical Subject Headings (MeSH) is the controlled vocabulary used by the NLM to index articles and to search MeSH-indexed databases, including MEDLINE. I suggest that Davis and Pless should persuade the NLM to remove "accident" from MeSH. This is an even higher upstream intervention.
Removing the comforts of the negligent majority 8 June 2001
Douglas Carnall, General practitioner Hackney, London, UK Send response to journal: Re: Removing the comforts of the negligent majority	EDITOR--I applaud your progressive decision to make authors and sub-editors think harder as they prepare reports of injury events. My main interest in the phenomena formerly known as accidents has been in considering how conditions for cyclists might be improved on urban roads. 1 The main reason that non-cyclists cite for not cycling is fear of trauma.2 Plainly, such people do not believe that any collisions will be "accidental"; they judge the road environment hostile, and avoid it, to their own, and society's loss. The risks of trauma are generally overperceived. But on the road at least, almost all traumatic events are brought about by deliberate human agency: driving too fast--perhaps a pitiless 30 mph (48 km/h) past a primary school in the rain; driving while you dial your mobile phone; failing to anticipate the needs of an elderly pedestrian from your bubble; and so on. My mother was standing on an Edinburgh pavement when a lorry driver ignored the need for a banksman when reversing across pedestrian space, crushing her lumbar vertebrae and pelvis. Another driver misjudged overtaking my father, who was mounted on his bicycle. My father fell, shattering the head of his femur. Either injury, executed with a baseball bat, would have resulted in a custodial sentence for the offender. But we exempt negligent drivers, largely, I think, for the practical reason that they are the majority. But at least we can recognise that "accident" is more often a word of consolation for the guilty than a useful scientific descriptor. References 1 Carnall D. Cycling and health promotion. BMJ 2000;320:888 2 The cyclesafe framework. CTC. Godalming, Surrey. June 2000.
I admire your stance on this issue 8 June 2001
Grier Bannon, Occupational Health Nurse in Remote Minesite in Western Australia WIndimurra Vanadium Mine Via Mt Magnet Western Australia Send response to journal: Re: I admire your stance on this issue	You are right accidents do not just happen. They are the product of poor management, lack of training, being unwilling to think about the task or situation, custom and practice and the list goes on. I'm not sure what word in our language we should use to replace "accident". I think this will develop some very healthy debate on this subject. One way to view an "accident" is see it as a system out of control or the inherent stable errors in a system have become unstable (Hegney Damage Model). Cheers Grier Bannon RN RMHN Dip OH&S ASIA
"accident" survivors 8 June 2001
John Sery, Environmental Health Services Branch Chief/Injury Prevention Specialist Indian Health Service, Billings, Montana, United States Send response to journal: Re: "accident" survivors	I was pleased to read the article concerning banning the use of the word "accident(s)". My work over the past 30 years has included a great deal of injury prevention. The term "accident" has always seemed to allow those injured something of a release from personal responsibility. Your article asked for possible alternatives to using the word accident in reference to survivors of different types of events. How about just calling them survivors? If an article in the newspaper deals with a car crash then it can refer to the injured victims of the crash as the survivors. Other examples could be considered, but in the end those who made it through the event have survived and are survivors. Perhaps, and hopefully, the term accidents as it is now poorly used will fade into the past. Perhaps not; tradition dies hard. Whether it does or not, personal choice and responsibility is most often what determines the outcome of the event.
Precise terms lead to precise findings 9 June 2001
Mary Overpeck, Epidemiologist U.S. Maternal and Child Health Bureau Send response to journal: Re: Precise terms lead to precise findings	Congratulations to Davis and Pless for their thoughtful article. As noted in other responses, lack of clarity in terminology many years ago for other medical events tended to hide the nature of conditions. A good example used already is 'heart disease' or 'heart attack', often used for a large range of possibly unrelated events. Poor specificity led to poor understanding. Similarly, injuries represent more global events. What is wrong with the generic term, 'injury'? If no injury resulted from an event, then describe the event. For example, 'injured in a car crash' is simple - but gives a more precise understanding of what happened. If intent is known, then intent may be mentioned. The word 'injury' does not connote intent. The word 'accident' does connote an 'act of God' in the minds of many. We are less likely to try to prevent acts of God. We are also less likely to narrow our preventive focus on the specific causes of injuries when they are ALL 'ACCIDENTS'.
BMJ bans "accidents" 9 June 2001
Liz Iwanowski, Area Occupaitonal Health Nurse Administrator USPS Send response to journal: Re: BMJ bans "accidents"	I like the work incident for most cases. Incident=an occurance or event that interrupts normal procedure or precipitates a crisis. An industrial/occupational "accident" is almost universally attributed to the employee doing something wrong. It's so much easier to do that then to look for the actual cause and pre-"accident" causes that could have prevented an incident. Survivors - could just be listed as fire, burn, MVA, etc. survivors.
BMJ who? 9 June 2001
Jim McKnight, N/A Transportation Research Associates Send response to journal: Re: BMJ who?	The large numbers of scientists, engineers, safety practitioners and others engaged in the study and prevention of accidents will continue to use the term in reference to an unintentional event resulting in harm. No other word encompasses the broad range of household, occupational, recreational and transportation accidents.
Accident is a kind word 11 June 2001
Elaine Sugden, Consultant in Clinical Oncology Dept of Clinical Oncology, Churchill Hospital, Oxford Send response to journal: Re: Accident is a kind word	Dear Sir, So, the BMJ has sold out to the culture of blame. (BMJ bans ‘accidents’) It wasn’t 1st April so we must assume the article was serious. If, apart from acts of God (which are also suspect) or bad luck (which isn’t), everything is preventable, then someone is always to blame. Yesterday I had a car accident, sorry, a car crash. Was it my fault for being in the way when the lorry driver wanted to change his mind about the direction he needed, or his fault for changing his mind, or the fact that we allow huge left hand drive vehicles on our roads so that he was unable to see my car behind him when he reversed, or was it because the road signs were unclear? Well of course it was his fault not mine; there was no argument. But if I had not been in his way, if the signs had been clearer, if he had been able to see me, all would have been well. Accidents are usually exactly that - a constellation of untoward events. Of course we work towards their reduction: seat belts, air bags, cycle helmets (now there’s a thought) etc. Accident is a kind word, it does not blame. Shame on you BMJ editors, there must be more worthwhile battles to fight. Yours faithfully Dr EM Sugden Consultant Clinical Oncolgist Churchill Hospital, Oxford OX2 0NA
Congratulations on taking a stand 11 June 2001
Lou Romig, Pediatric emergency specialist Miami Children's Hospital, Miami, FL., USA Send response to journal: Re: Congratulations on taking a stand	Bravo for BMJ's decision to restrict the use of the word "accident" in your publication! As a pediatrician and emergency physician, injury and illness prevention is a considerable part of my patient and family counselling and education. I'm notorious in my ED for quickly correcting all who use the term "MVA" or otherwise inexactly use the word "accident" in the context of an injury. When I explain why I dislike the term, I can see virtual lightbulbs clicking on over people's heads as they almost universally say "You know, I never thought about it that way." So, congratulations on taking what may be an unpopular stand. Efficient injury and illness prevention must begin with each one of us realizing that we can make individual differences for ourselves, our loved ones, and our patients. Lou Romig MD, FAAP, FACEP Pediatric Emergency Medicine Specialist Miami Children's Hospital, Miami, FL, USA
Shall we Ban 'Non-Accidents' ? 12 June 2001
Benjamin Jacobs, Locum Consultant Paediatrician Whipps Cross University Hospital, London Send response to journal: Re: Shall we Ban 'Non-Accidents' ?	The editors of the BMJ wish to ban the term 'accident'. Perhaps paediatricans should then replace the term 'non-accidental injury' (NAI) with 'intentional injury' (II)?
WHAT'S IN A NAME? 12 June 2001
Gordon Webster, Employee Case Manager Australia Post Send response to journal: Re: WHAT'S IN A NAME?	What I'd like to know is what do you anticipate will change by using another word instead of 'accident'? And what would that word be anyway......something like 'incident'? I expect the reason for the name change is to stop the thinking in people that 'they couldn't stop it' and to enforce and make them believe that accidents are always preventable. .......but how do you propose to change that way of thinking and how will you market it? Perhaps by changing the word, individuals involved will feel more responsible for what has happened.......but that remains to be seen.
Reply to our readers 12 June 2001
Ron Davis, North American editor, BMJ; editor, "Injury Prevention" Henry Ford Health System (Detroit, Michigan, USA); Montreal Children's Hospital (Canada), Barry Pless Send response to journal: Re: Reply to our readers	Reply to our readers We appreciate the thoughtful comments from readers about our editorial on banning "accidents." As of 11 July, 50 rapid responses had been posted, divided equally among those supporting and opposing our new editorial policy. We have had a similar debate about the policy among the editorial staff of the BMJ, reflecting strongly held views on both sides of the issue. After carefully considering all of the comments we've received, we continue to believe that we have chosen a proper course of action. Here are some of the key arguments against our new policy and our responses: 1. "Accident" is a perfectly good term and its meaning is not ambiguous. We disagree. The commentary running through the first 50 rapid responses has confirmed that the word has many different meanings. One responder noted that "accident" can refer to the event, the injury, or the precursors of the event. Another added that it covers "everything from spilled milk to death." 2. Some "accidents" occur when no one is to blame. "Accidents" do occur. We agree, and as we pointed out in our editorial, "some injury producing events may seem to be attributable to bad luck or acts of God and thus not preventable." But in the case of most injuries, risk factors were present before the injuries occurred and could have been eliminated or diminished. In some cases, the injury-producing event is difficult or impossible to predict or prevent, but steps can be taken to reduce the risk or severity of injury. It may be impossible, for example, to avoid a collision with a drunk driver who crosses into opposing traffic. But wearing a safety belt, driving an automobile with an air bag, and avoiding excessive driving speeds will almost always reduce the severity of injury when an unavoidable collision occurs. 3. At the population level, most injuries are predictable and preventable. But at the individual level, they are not. Injuries at the individual level are predictable and preventable only by hindsight. We disagree. Safety experts see injuries waiting to happen as soon as they enter unsafe environments. The challenge is to extend that same sensitivity to all those who control the safety of homes, vehicles, schools, worksites, medical facilities, and other venues where injuries often occur. If schools do not have a soft surface below playground equipment, if parents store medications where they are easily accessible to children, if factory workers do not use proper protective gear, and if hospitals store concentrated potassium chloride (instead of appropriately diluted solutions) on patient care units, then injuries will predictably occur—with foresight as well as hindsight. 4. Most people understand that "accidents" are preventable. In a national survey of 943 adults in the United States, Girasek found that 83% believed that "accidents" usually could have been prevented.[1] This means, of course, that 17% did not hold that belief. In addition, the survey showed that only 25% of respondents believed that "accidents" usually could have been predicted, and that 26% believed that "accidents" are controlled by fate. Moreover, subjects with less education were less likely to believe that "accidents" are predictable, and more likely to believe that "accidents" are controlled by fate. These findings do not contradict the statement in our editorial that "An accident is often understood to be unpredictable—a chance occurrence or an "act of God"—and therefore unavoidable." If many people hold that belief, especially within disadvantaged strata in the population (as the findings by Girasek would seem to indicate), then the case for eschewing "accident" is supported. But beyond the matter of preventability and predictability, the imprecision of the meaning of "accident" is reason enough to avoid using it in scientific discourse. 5. You are censoring the English language; your policy is Orwellian and totalitarian. Some of this commentary, we suspect, was a reaction to the word "ban." Although the title and first paragraph of the editorial announced a "ban" on "accident" without qualifiers, the rest of the editorial explained that we are banning "inappropriate use" of the word, that "implementation of the ban will not be draconian," and that there will be exceptions when "accident" is allowed (see item #10 below). We believe that in most instances, the word is used inappropriately or it can be replaced easily with alternative language. Thus, we expect that the appearance of the word will fall substantially in—but not disappear from—the BMJ. We see nothing Orwellian about the policy. Every language, including English, varies from place to place and changes over time. Differences within a language are seen among ethnic, geographic, and socioeconomic groups in a population. Occupational disciplines develop their own professional languages, which often redefine or reject common lay terms. To insist that a scientific publication use a lay term with its ambiguous lay meaning strikes us as much more Orwellian and anti-language than our new policy. One of the responders compared the word "accident" to the word "heart attack." If a cardiology journal rejected use of the term "heart attack" in its research papers, would we cry "censorship"? 6. Deliberate attempts to change the English language have failed in the past. We agree. But our main goal is not to change the English language wherever it is spoken. Our primary objective is to speak clearly and properly within the BMJ. We hope that other communicators in medicine and science will do the same. When that happens, perhaps the move away from "accidents" will trickle down into the general population, but we will not hold our breath waiting for that to happen. 7. There is no evidence that banning "accident" will reduce the burden of injuries. We agree. But there is no evidence that avoiding the word will cause harm. As we see it, the benefit of speaking clearly and properly is justification enough for the new policy, in the absence of "hard evidence" regarding good or bad outcomes. As we state in the editorial, "we believe that correct and consistent terminology will help improve understanding that injuries of all kinds ... are usually preventable. Such awareness, coupled with efforts to implement prevention strategies, will help reduce the incidence and severity of injuries." (emphasis added) 8. Banning "accident" contributes to a culture of blame. This argument doesn't get to the crux of the issue. The word "accident" has an effect on the attribution of blame, whereas "injury" is neutral in regards to blame. Because of its connotation that the event was unpredictable or unavoidable, "accident" protects against blame. When we use "accident," we exonerate from blame the person injured, the parent, the manager, the facility, the company, or "the system." In so doing, we discourage the search for root causes and their remediation. On the other hand, as one of the responders noted, "The use of the term injury rather than accident focuses attention on the damage to the person and what can be done to prevent this damage." 9. If we ban "accident," we will ignore the lessons to be learned from examining "near misses." Abandoning "accident" and focusing on the injury and its antecedents does not preclude attention to "near misses." It simply means that we will not refer to near misses as "accidents." Schemes for reporting near misses have been institutionalized in several non-medical sectors such as aviation, nuclear power technology, petrochemical processing, steel production, and military operations; and similar reporting systems are being developed in medicine. These systems employ many terms besides "accidents" to describe near misses, including "near misses," "close calls," "errors," "unsafe actions," "critical incidents," "dangerous occurrences," "sentinel events," "non-consequential events," and "adverse events" (eg, "adverse drug events").[2] 10. Banning "accident" will waste hours of editors' time searching for clumsy replacement language. We have heard this concern from some BMJ editors, and one of the rapid responses (from a copy-editing manager) stated that "most will have great difficulty ... knowing which word to use when." Despite those misgivings, we are optimistic that editors and copy-editors (sub-editors) will have little difficulty in finding replacement language. With experience, the task should become easier. Some journals have been working for many years to abstain from "accidents," such as Injury Prevention (published by the BMJ Publishing Group) and Morbidity and Mortality Weekly Report (published by the US Centers for Disease Control and Prevention). Neither the editor nor the technical editor of Injury Prevention has had difficulty in replacing "accident" with "injury" or some other phrase. When MMWR is forced to use "accident"—for example, when it publishes national mortality data for which the term is still used—it adds this footnote: "When a death occurs under 'accidental' circumstances, the preferred term within the public health community is 'unintentional injury.'"[3] The "injury control community" in North America has been successful in communicating about injuries without "accident." If other journals and people who work in the field can find a way to avoid using the word, then the BMJ and other journals should be able to do so as well. Our editorial provided suggestions for alternative wording. We are willing to serve as resources to BMJ editors and others when they are struggling to avoid "accidents." If instances occur when the clumsiness quotient is too high, then "accident" should be allowed. And as mentioned above and in our editorial, there will be exceptions when "accident" is considered acceptable and alternatives need not be sought. MMWR, for example, published recommendations recently on responding to fecal accidents in swimming venues[4]; we would not be troubled to see "fecal accidents" in the BMJ (on the BMJ would be a different matter). One of us (RD) went through the exercise of purging "accident" from a recent BMJ paper (on handlebar injuries from bicycle "accidents") in which the word appeared several times.[5] Here are the results: Paragraph 1, sentence 1: Change "Accidents" to "Unintentional injuries." Paragraph 1, sentence 2: Change "after bicycle accidents in children" to "when bicycle falls and collisions occur among children." Paragraph 1, sentence 3: Change "Bicycle accidents" to "Bicycle falls and collisions." Paragraph 1, last sentence: Change "accident" to "incident." Paragraph 9, sentence 2: Change "motor vehicle accidents" to "motor vehicle collisions." Paragraph 10, sentence 1: Change "Bicycle accidents" to "Bicycle falls and collisions." Paragraph 11, sentence 3: Change "Bicycle accidents" to "Bicycle falls and collisions." Paragraph 11, last sentence: Change "accidents" to "incidents." Ron Davis North American editor, BMJ Barry Pless editor, Injury Prevention 1. Girasek DC. How members of the public interpret the word accident. Injury Prevention 1999;5:19-25. 2. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-63. 3. US Centers for Disease Control and Prevention. Mortality patterns—United States, 1997. MMWR 1999;48:664-8. 4. US Centers for Disease Control and Prevention. Responding to fecal accidents in disinfected swimming venues. MMWR 2001;50:416-7. 5. Lam JPH, Eunson GJ, Fraser DM, Orr JD. Delayed presentation of handlebar injuries in children. BMJ 2001;322:1288-9.
Which accidents are preventable and which are not? 12 June 2001
Ed van Beeck, associate professor of public health/ head injury epidemiology unit Department of Public Health, Erasmus University Roterdam/ Consumer Safety Institute, Amsterdam, Saakje Mulder Send response to journal: Re: Which accidents are preventable and which are not?	With interest we have took notice of the recent editorial by Davis and Pless, where they announce that the BMJ has decided to ban the word accident(1). We are informed that the "editors are asked to be vigilant in detecting and rejecting inappropriate use of the "A" word". As researchers involved in injury epidemiology for many years, we were aware of the repetitive plea of opinion leaders to take this step. Nevertheless, we were greatly surprised when reading that the BMJ has been the first major medical journal that has actually taken this decision. Our surprise stems from the fact that we are not convinced by the author's arguments to do so. After reading the editorial we are left with many questions. Why should we ban the word ''accident''? What is the empirical evidence to support this ban? Did the "A" word have a negative influence on implementing injury prevention in the past? Is there a better term available? Davis and Pless do not give us the answers. They use the following reasoning for the ban: "An accident is often understood to be unpredictable and therefore unavoidable". The question then rises 'by whom?' The only empirical study on this issue has been executed among the lay public. This showed that a majority of laypersons indeed think that accidents cannot be predicted, but they do not make a link to unavoidability at all(2). Davis and Pless continue with "However, most injuries and their precipitating events are predictable and preventable. That's why the BMJ has decided to ban the word accident". They come up with three references without any quantitative support for their statement. This is not surprising since injury epidemiology has not yet delivered this type of support, contrary to, for example, cancer epidemiology many years ago(3). Therefore, we think, that instead of spreading a general belief in prevention, we should first try to unravel the problem: which accidents are predictable and which are not? what is the contribution of factors that can be influenced by prevention? which preventive measures are available and what is their effectiveness? Because of the size and heterogeneity of the problem field, many of us will have to make a contribution to move the field forward, as others did in the past (4). We must not forget that accident prevention belongs to the ten great achievements of public health over the past century(5), in spite of the widespread use of the "A" word. Why then ban the term? Is there a better one available? The authors admit that there is not. Here we agree with them. We also agree, that in order to move the field forward an international standard for classifying injuries and their external causes is of great importance. Under the authority of the World Health Organisation, such a standard was developed and tested. This led to international consensus and to the first draft of the International Classification of External Causes of Injury (ICECI)(6). The glossary of ICECI includes the word ''accident'' which is referred to as a synonym for unintentional injury event: ''an unforeseen incident, where the intent to cause harm, injury or death was absent, but which resulted in injury'. This classification may provide a basis for specified injury surveillance and research, which could contribute to a further reduction of accidents and their health consequences. Simply banning the term accident will probably not. Ed van Beeck, MD PhD, Department of Public Health, Erasmus University, Rotterdam, Netherlands Saakje Mulder, MSc, Consumer Safety Institute, Amsterdam, Netherlands References 1. Davis RM, Pless B. BMJ bans "accidents"-accidents are not unpredictable-.BMJ 2001;322:1320-1 2. Girasek DC. How members of the public interpret the word accident. Injury Prevention 1999;5:19-25 3. Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. JNCI 1981:66-6 4. Gordon JE. The epidemiology of accidents. Am J Public Hlth 1949;39:504- 515 5. CDC. Ten great public health achievements- United States, 1900-1999. MMWR 1999;48:241-243 6. Consumer Safety Institute. Data Dictionary : International Classification of External Causes of Injuries (ICECI) : ICECI Version 1.0. Amsterdam: Consumer Safety Institute; 2001.
Logic and language 15 June 2001
Frank Haight University of California Irvine Send response to journal: Re: Logic and language	Dear Dr. Davis: My friend and colleague Herbert Moskowitz has just called my attention to your editorial "BMJ bans 'accidents'". Dabbling in language is best left to language journals. Think carefully over the penultimate paragraph in which you lament the inadequacy of English. It is precisely that inadequacy that has led to the use of the generic term "accident".Sorry to tell you "injident" won't survive; politically correct language is already dying on the vine. If someone thinks an accident is predictable, let that person step forward and predict the time and place of one, i.e. the details that go into a standard accident reporting form. Don't escape by talking about long range averages; in that sense flipping a coin is predictable, too. We learned many years ago (with seat belt wearing) that injury can be preventable without being predictable. Conversely you yourself give examples of things (certain natural disasters) that are predictable without being preventable. By attempting to equate predictable and preventable you are setting up a straw horse that even a clever high school student can knock down.. It leads to the massive non sequitur "This is why BMJ has decided . . ." With best regards, -=frank haight=- P. S. After reading your comments section I was struck by the frequency with which readers wished to replace "accident" by "injury". Please be advised that, in the field of traffic safety, not all accidents result in injury. More frequently (and at about equal cost) are accidents called PDO (property damage only). Of course everyone is privy to "what people think" I've been thinking about the subject for 33 years, and here is what I think: "The semantics of safety" Journal of Traffic Medicine Vol. 26, No. 3 -4, pp. 67-72
Problem driving; an accident waiting to happen. 18 June 2001
Laurence Jerome, Consultant Psychiatrist London Ontario Send response to journal: Re: Problem driving; an accident waiting to happen.	We applaud Davis & Pless in their quest to improve scientific nomenclature in the area of injury prevention. Current research by my colleagues and I, in the area Human Factors in Driving "Accidents / Near accidents" suggests that inattention & speeding contribute significantly to "unpredictable" accidents in new novice drivers. Measurable traits of impulsivity,predict the liklihood of increased "accident" potential, thus allowing the development of primary preventative strategies in those drivers shown to have high levels of impulsivity in their driving styles, prior to any "accidents". Should we call this Problem driving behaviour or an "accident waiting to happen "? Laurence Jerome
Accidentally on purpose 21 June 2001
Stephen Due, Medical Librarian Geelong Hospital Library Send response to journal: Re: Accidentally on purpose	How sad to see the editors puzzling over the meaning of a common and easily understood word. Sadder still their desire to ban it, revealing an irrational belief that such an action will advance medical science. It is common knowledge that an accident may be both predictable and preventable, and your attempt to convince the reader that people believe otherwise is unconvincing. If you want people to try to predict and prevent accidents, why not just say so? Your proposal to use "injury" instead of "accident" is unlikely to work, since the words are not synonymous (if they were, you would not have made the suggestion, presumably). Your editorial stretches the reader's credibility to the point where it seems there must be some motive behind it other than the simple desire to improve written communication or mould medical opinion with regard to accidents. Surely you would not descend to printing editorials deliberately designed to provoke correspondence? As your readers, we like to be interested and informed, and occasionally perhaps entertained or even astonished, but we would rather not have to grapple with the mental confusion evident in this editorial, which lacks the better qualities we have come to expect from you.
A Not So Splendid Isolation 21 June 2001
Wim Rogmans Editor of the Journal for Injury Control and Safety Promotion Send response to journal: Re: A Not So Splendid Isolation	The proposal by Davis & Pless to ban the word "accident" from now on in your Journals is in my opinion totally overdone and does not speak to: - existing diversity in languages around the world, where "accident" or equivalent terms not always have that "Act of God" - annotation as it has in the Anglosaxon language and where people should have the right to continue to use their equivalent term (and the English translation into accident); - the interest in safety promotion from other disciplines than the medical one only. These disciplines (industrial design, communication and behavioral sciences) have a lot to contribute to safety promotion but certainly will not buy the term injury. Your medical dominated constituency will certainly further estrange itself from the broader interdisciplinary community that's interested in safety promotion.
The power of language 21 June 2001
Jennifer Mindell, Honorary clinical lecturer department of Epidmiology & Public Health, Imperial College Send response to journal: Re: The power of language	Avoiding the use of the word "accident" is not political correctness but may help to change attitudes and reduce injuries. It is something the Transport and Health Study Group has been advocating for a number of years. "Accident" means unintentional but in both professional and lay use is often used to imply "unavoidable". In most cases, more accurate words are available. I suggest "falls" and "collisions" to describe the majority of events and "injuries" to refer to the damage people (or animals) sustain as a result. The proposed neologism ("injidents") is unnecessary, counter-productive, and could be considered a serious symptom in the editorial board.
Safety is not #1 22 June 2001
Linda Long, occupational safety consultant Michigan Send response to journal: Re: Safety is not #1	Words are very powerful. The subtle acceptance that accidents are unavoidable continues to promote the mentality that safety should be treated different than other work rules. I dare say, an employee would more likely be disciplined for stealing a screwdriver than replacing a motor without locking out the power. Putting safety on a pedestal as #1, guarantees it'll never recieve the same considerations as every other work rule. Accepting the term "accident" as a description of an incident resulting in an injury arises of the same mentality that accepts the idea that 85-90 percent of all workplace accidents are unsafe acts (the rest are unsafe conditions). My experience of investigating hundreds of accidents has taught me that the opposite is true. A true unsafe act (i.e. first time, single-person involvement, un-detected/observed by management) could be a true accident. Those are rare. The tendency in industry to not insist on accountability regarding safety rules leads to 'babysitting' mentality and transforms what was once an unsafe act to an acceptable (unsafe) condition of employment. "Injevents" would denote that all 'accident' events resulted in an injury. It is possible, and occurs frequently, to have an accident/incident event which does not result in an injury (injury event). This is usually the result of luck, use of personal protective equipment or other safeguards. So would an 'injevent' without injury be an 'event'. I don't have a good idea, but I do agree with your idea.
On indijents and injuries 22 June 2001
Eleni Petridou, Ass. Professor of Epidemiology Athens University Medical School Send response to journal: Re: On indijents and injuries	Sir, We beg to disagree with your decision to ban “accidents” from your columns. We do that with considerable trepidation, since we are not even fluent in English as your distinguished Editorialists are1. We are all aware that the deterministic and the stochastic schools have argued forever with the pros and cons of their perspectives in the study of causation and we consider ourselves, if anything, Popperian determinists2. Yet, we still believe that the collective influence of factors that cannot be determined or ascertained has to be turned to the realm of chance. Would the extreme determinism also ban the standard error from statistics or the residual variation from the analysis of variance? Prominent scientists have openly used the term “luck” in their consideration of cancer etiology3, and there is no reason to believe that molecular events or processes are any less deterministic than the influences surrounding the events that leads to injuries. Words can have powerful implications and can become offensive to individuals or ethnic groups, particularly if they are meant to be offensive. In this instance, however, who is going to be defamed, the injidents for being called accidents? The only plausible consequence, and an unpleasant one, would be the generation of a new wave of victim blaming, as Gerasek4 has pointed out. Does anyone care to remember why and how workers were labeled as “accident prone”? History has taught us that we can not solve problems by exorcising words. Moreover, we should perhaps be more reluctant in deciding between the stochastic and the deterministic perspective of causation, on the basis of an issue that may or may not be central in the more general context. Eleni Th. Petridou1,2 Dimitrios Trichopoulos1,2 1 Department of Hygiene and Epidemiology, Athens University, Medical School, Athens Greece 2 Department of Epidemiology, Harvard School of Public Health, Boston, USA References 1. Davis MR. Pless B. BMJ bans “accidents”.BMJ 322: 1320-21. 2. Popper K, R. The logic of scientific discovery. New York: Harper and Row, 1965 3. Doll R and Peto. The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today J Natl Cancer Inst 1981;66:1191- 1308. 4. Gerasek DK. How members of the public interpret the word accident. Injury Prevention 1999; 5:19-25. Address for correspondence: Dimitrios Trichopoulos , Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, MA 02115, Boston, USA Email: dtrichop@hsph.harvard.edu
Change is inevitable 23 June 2001
Gary Kesling, Assistant Professor The University of Texas Medical Branch Send response to journal: Re: Change is inevitable	Terms and definitions change over time. For example, about 400 B.C., Hippocrates used the terms "mania" and "melancholia" to describe mental disturbances. The term melancholia was used by by other medical authors throughout history. Today the term can be found in DSM IV as " melancholic features". Terminology changes over time. We see and hear less about "meancholia" today because the language has changed. Maybe in the near future we will hear less about "accidents and more about their features".
BMJ bans 'accidents' 26 June 2001
John Heyworth, Consultant Southampton General Hospital Send response to journal: Re: BMJ bans 'accidents'	EDITOR - Despite the Orwellian tone of the title [1], this move away from semantic inconsistency is welcome. Rather than wrestle with clumsy permutations or neologisms, we should describe each event individually to ensure accuracy and clarity. The authors rightly draw attention to the recent change in title of the Journal of Accident and Emergency Medicine to Emergency Medicine Journal, a relatively small step but fundamental in describing the evolution of the specialty. The predominant trauma base has been superseded by an increased involvement in the range of emergency care including acute medicine, critical care, toxicology and paediatrics, as well as injury. It is out intention that the name of the specialty should also change to 'Emergency Medicine' to correctly and succinctly reflect our current and future practice, in line with the international nomenclature of the specialty. This will take time to become universally used as illustrated by Minerva [2] in the same week referring to injured cyclists in Sheffield attending their local 'casualty' department-an accident surely! John Heyworth Consultant Emergency Medicine Emergency Department Southampton General Hospital Southampton SO16 6YD john.heyworth@suht.swest.nhs.uk 1 Davis R, Pless B BMJ bans 'accidents' BMJ;2001:1320-1 2 Minerva BMJ;2001:1374 No competing interests.
The Word 'Accident' 28 June 2001
Michael Cox, Retired GP N/A Send response to journal: Re: The Word 'Accident'	Editor, Banning an inoffensive word could seem like the delusion of grandeur that we used to associate with G.P.I. As this is unlikely, could it be an editorial accident? Michael I. Cox GP (retired) Caldbeck, Cumbria CA7 8EU
Error is no accident 28 June 2001
Andrew Lingwood, 4th Year Medical Student UNSW, Staff Specialist, Director Ambulatory Care Macarthur Health Service, Nicholas Collins, Stephen Wilson Send response to journal: Re: Error is no accident	We share Davis and Pless1concern regarding the inappropriate use of “accident” in the medical literature. A search of Medline from 1995 to 2001 using “accident” as a keyword confirms the widespread use of the term in the medical literature with a total of. 19229 references. There is undoubtedly much inappropriate use of the word accident when we review its definition as an event without apparent cause that is unexpected, unintentional and related to chance2. The term ‘medical accident’ raises much controversy, and can have medicolegal ramifications. Calling an adverse medical event a ‘medical accident’ may be seen as an attempt to absolve the involved parties of fault because an accident is an unintentional, unfortunate event without apparent cause. While we would assume and hope that these ‘medical accidents’ are unintentional, to suggest apparent cause or are even unavoidable is clearly wrong and misleading. A prevailing culture of blame and punishment for making mistakes discourages doctors who do err from discussing errors and trying to prevent them in the future3,4. Instead, the error is dismissed as an unfortunate and perhaps implicitly unavoidable event. The 1999 report of the Institute of Medicine5, defines a medical error as a failure of an action or plan and discourages the description of errors as either accidents or “blunders”. The latter reinforces the notion of personal blame and failure which promotes hiding the error and worsening the outcome for the patient. It is important, that if we are going to remove the word accident, that we have a replacement term that is more useful and precise. We have applied the term variance to our quality improvement programme to describe events which deviate from the expected course of best practice or evidence based guidelines. We believe this allows for the inclusion of both the unexpected and the statistically predictable events without also including a notion of blame. 1 Davis RM, Pless B. BMJ bans “accidents”. BMJ 2001;322:1320-1. 2 New Oxford Dictionary of English. Oxford University Press: Oxford. 1998. 3 Tanne JH. AMA moves to tackle medical errors. BMJ 1997;315:970. 4 MacReady N. Second stories, sharp ends: dissecting medical errors. The Lancet 2000;355:994. 5 Kohn LT, Corrigan JM, Donaldson MS. To Err is Human – Building a Safer Health System. Washinton, USA: National Academic Press, 1999.
Inevitability vs. Preventability 30 June 2001
Leila M Hover Integrated Communications Corp Send response to journal: Re: Inevitability vs. Preventability	Editor--The editors' ban on accidents (1) resonated with me as I had recently completed a paper in my doctoral program on the Challenger "accident." Allinson, who has written extensively on this accident, addresses the preventability rather than the inevitability of its occurrence, since he sees it as anything but an accident although the "implication is that it was not foreseen" and that "it is conceived of as an event that could not be avoided, and, by extension, all further events of similar kinds should (and will) be considered accidents. There is not a great deal one can do about accidents since accidents will happen and accidents are inevitable." (2) This fatalistic attitude has spread and become endemic. However, many engineering reports were written warning of the failure characteristics of the O-rings for the booster rockets, and it was only a matter of time as to when this rocket would fail, but it was not an accident. It was foreseen, it was predicted, and the predictions were ignored. In this case there were no survivors and no opportunity to apply the neologism (injidents) suggested by the editor. But the use of "accident" as applied to the more mundane and usual occurrences of everyday life is better put aside since a good many of these occurrences can also be reasonably foreseen: the drunk driver, the worker careless about safety, etc. What will the language supply in its stead? That remains to be seen, but assuredly something will take its place, if only by accident. Leila M. Hover Director, Scientific Information Candidate, D.M.H. Integrated Communications Corporation, Parsippany, N.J. Lhover@icclink.com 1 Davis R, Pless B. BMJ bans "accidents." BMJ 2001; 322:1320-1 (2 June) 2 Allinson, RE. Global Disasters: Inquiries into Management Ethics. New York: Prentice Hall, 1991.
How should we rename NAI? 6 July 2001
Martin Wiese, SpR (LAT) in Emergency Medicine Kent & Canterbury Hospital Send response to journal: Re: How should we rename NAI?	EDITOR – The journal’s pledge to avoid the future use of the traditional term "accident" marks an important step towards a clear medical language that will help raise awareness of the avoidable or preventable nature of the circumstances under which the majority of injuries are sustained. The "ban" is a welcome chance to re-examine a wide range of areas in which the word "accident" is used inappropriately. In their editorial, Davis and Pless comment on the implications for the speciality of "Accident & Emergency Medicine" and correctly suggest its renaming to "Emergency Medicine". [1] Other implications will soon emerge as the acceptance of the concept grows. An important one involves the only type of injury currently specifically termed non-accidental (in order to imply intent) – the physical abuse of children. If we believe that almost no injury can be called truly accidental, then the term "non-accidental injury" becomes meaningless. This is more than a linguistic curiosity. It is our duty to think and communicate clearly about the circumstances under which children suffer injuries caused by people close to them, and I therefore propose that the term "non-accidental injury" be abandoned. What should we use instead? This issue should be discussed as widely as possible. 1. Davis RM, Pless B. BMJ bans "accidents". BMJ 2001;322:1320–1
Imperial accidents and Injuries 7 July 2001
John Lascaratos, Associate Professor Athens University Medical School Send response to journal: Re: Imperial accidents and Injuries	Imperial accidents and injuries John Lascaratos,Assoc. Professor of History of Medicine Athens University Medical School Send response to journal: Re: Imperial accidents and injuries Email John Lascaratos : giannop @ power. ece. ntua. Gr Sir,We have followed the various opinions of your readers about the meaning of “accident” and we have recalled to mind some historical accidents, from the thousands of such cases, which imperial families suffered and which we think illustrate the meanings of the term “accident”. The case of the heir to the Austro - Hungarian throne, Rudolph (1858-1889) who committed suicide, under doubtful circumstances, with his mistress Maria Vetsera during the hunt at Mayerling, may have been such a kind of “accident” as the recent case of the massacre of the Nepalese royal family. There is, however, a historical case in the Byzantine empire which has the characteristics of an accident as many of your correspondents would have defined it. The then emperor of Byzantium was Andronicus II Palaeologus, the Elder (1283-1328) with co-emperor his son Michael IX (1294-1320). The son of the later and heir to the throne, Andronicus, was the particular weakness of his grandfather. He was “an attractive and gifted youth of handsome appearance” but superficial, indifferent to public affairs, preferring entertainment and many sexual adventures. An accident which was due to his sexual affairs had dramatic consequences for the ruling Palaeologus dynasty and the whole empire.1The young Andronicus was madly in love with a young girl of the nobility who, however, was of loose morals. As the historian Gregoras2 states “She had the behaviour of an ancient hetaira (courtesan) at least, not to say anything more”. He suspected, as the historian adds, that some other young “Adonis” was her lover at the same time and visited her house in his absence. His jealousy fired his soul and he sent a permanent guard of archers and sword-fighters to keep a secret watch on the house and dispose of his rival. It chanced one night that Andronicus’ brother, Manuel, went to the girl’s house to look for him. The guard, due to pitch darkness, took him for Andronicus’ rival and all shot arrows at him, causing him to collapse, dying, from his horse. When the guard approached him, they realised their tragic mistake and quickly moved him to the palace, where he died.What followed was dramatic. The father of both brothers co-emperor Michael, suffered a fit of apoplexy due to his grief3 and died after eight days at the age of 42. The grandfather survived the shock but, disapproving of the sexual passion of his grandson which had had such fearful consequences, excluded him from succession to the throne. The young Andronicus then began an insurrection, occupying a part of the empire (Thrace and an area of Macedonia) and proclaming himself emperor. The division of the empire and the Civil war between the two emperors which resulted in the disruption of Byzantium for many years, until the final success of the grandson who was installed as emperor with the name of Andronicus III, was due to an accident.Other accidents affected these same personalities : Andronicus II died after eating shellfish which caused acute gastroenteritis. Andronicus III suffered a number of accidents which caused severe injuries in battles against the Turks, finally escaping every one of them. He died from “a natural accident” - malaria.4 John Lascaratos, Department of History of Medicine,Medical School, National Athens University References 1. Ostrogorsky G. History of the Byzantine State. London : Blackwell, 1986. 2. Schopen L. Nicephori Gregorae historiae Byzantinae. Vol. 1. Weber : Bonn, 1829. 3. Schopen L. Joannis Cantacuzeni eximperatoris historiarum libri IV. Weber : Bonn, 1828. 4. Lascaratos J. Diseases of the Byzantine Emperors. J and J Hellas : Athens, 1995. Address of Correspondence Dr John Lascaratos, M.D., Ph.D.Department of History of Medicine. Medical School. National Athens University164b Hippocratous str.11471 AthensGREECETel. (00301) 6426486Fax. (00301) 7796745
Re: The Word 'Accident' 17 July 2001
Malcolm Klein, Staff Anesthesiologist Universal Anesthesia Care, Tampa, Florida, USA Send response to journal: Re: Re: The Word 'Accident'	I applaud your initiative to find an alternative term for “accident”. I too have struggled for a suitable semantic substitute. The US military uses the term "mishap", while the US press for example loves the term "botched surgery" to describe an undesired surgical outcome. I think the term "injury event" may have promise. "Fatal or non-fatal injury event" provides further explanatory detail. However, "fatal injury event survivor" may be too clumsy. I look forward to more debate on this subject.
Accidents of God 29 August 2001
John Onorato, New Business Development ESAB Send response to journal: Re: Accidents of God	Dear Mr. Evans, You refer in your article on the misuse of the word "accident" for BMJ and for society in general, except in the case of God. I can assure you that in God there are no "accidents". God is the only place in society and in all the world where there are no "accidents". If God is the only proper use of the term "accident", as you suggest, then your very being could be an accident. I agree with your article, except that if you are struck by lightning or are involved in a car crash, it is inappropriate to be called an accident of God. If you live your life in God's hands, there are no "accidents". Respectfully submitted by John Onorato PS: Not even the giraffe was an accident.