Fatal Accidents

Issues of Concern

The United States and Canada

In the United States, accidental death, also described in the literature as death from unintentional injury, has accounted for approximately 5% of all deaths in recent years, totaling approximately 135,000 deaths annually. Since the beginning of the 21st century, mortality rates associated with firearms and transportation have declined, whereas deaths associated with falls, drowning, and accidental opioid overdose have increased. Drug overdose deaths increased by 23% from 2010 to 2014, with oxycodone and heroin ranking among the leading causes in 1 study. During the same period, heroin overdose deaths tripled in the United States, and cocaine ranked second or third among causes of overdose death, depending on the year.[4][5][6]

Very young children and older adults have an increased risk of accidental death. Results from 1 study showed that accidental injuries accounted for 38% of all pediatric deaths. In 2013, accidental injuries were the eighth leading cause of death among adults aged 65 years or older.

According to the United States Bureau of Labor Statistics, a review of occupational risk showed that logging had the highest mortality rate in 2015, with 110.0 deaths per 100,000 workers annually. Commercial fishing followed with 80.8 deaths per 100,000 workers, followed by aircraft pilots and flight engineers with 64.0, roofers with 47.4, refuse and recyclable material collectors with 35.8, and agricultural workers with 26.7 deaths per 100,000 workers annually. Men were consistently more likely than women to experience accidental death, particularly from occupational injuries. Accidental deaths, including occupational and nonoccupational deaths, were also more common among Black individuals than among individuals from other racial groups. This difference was especially notable for fire-related accidental deaths.

Results from a 2016 study by Darela et al showed that men diagnosed with prostate cancer who were advised to undergo definitive treatment but did not receive treatment represented a population at particularly high risk of death from accidental injury. Preventable accidental deaths were more common among individuals with lower socioeconomic status than among those with higher socioeconomic status. Limited access to safety information and protective equipment may partly account for this association. Socioeconomic status was not associated with deaths attributed to nonpreventable causes. Similar patterns have been observed in Canada.

Marital status has also been associated with the risk of accidental death. Results from multiple studies showed increased rates of accidental death among unmarried individuals compared with married individuals, including divorced, widowed, and never-married populations. Results from 1 longitudinal study showed that the risk of death from unintentional injury was 76% higher among divorced individuals, 41% higher among widowed individuals, and 35% higher among never-married individuals compared with married individuals. Unmarried men were twice as likely as unmarried women to die from unintentional injuries across all types of accidents. Results from the same study also showed that individuals living in the northeastern United States had a lower risk of accidental death than those living in other regions of the country.

A 2014 survey of poisoning deaths in the United States showed that poisoning-related mortality among individuals aged 15 years or older had increased by an average of 6% annually since 1979. Rates of increase did not differ substantially according to sex or race, although the absolute number of deaths was higher among men than among women. Opioid-related deaths have contributed substantially to this increase.

Results from a 2015 study conducted in San Diego showed that methadone accounted for 18% of all prescription drug-related deaths and was the most common individual drug associated with mortality. Only 29% of individuals who died from methadone-related causes had a registered methadone prescription in the California state database. However, a 2016 report from the United States Department of Health and Human Services described a national decline in methadone-related deaths despite increasing mortality associated with other opioids, particularly heroin.

International

Results from a study of Finnish residents of working age, defined as 15 to 65 years, showed that long-term unemployment was an independent risk factor for accidental drug-related death. The hazard ratio was 4.9 compared with age-matched employed individuals. Short-term unemployment and retirement were also associated with an increased risk of drug-related death, with hazard ratios of 3.9 and 5.8, respectively.

Results from a Swedish study of previously incarcerated individuals with known substance use disorders showed that male sex, heroin use, and cannabis use were associated with an increased risk of death from accidental drug overdose or injury. From 2003 to 2012, Norway experienced an increase in accidental deaths from poisoning, primarily due to opioid overdose, particularly methadone. These findings demonstrate the substantial contribution of substance use to accidental mortality across populations.

Results from a study of adolescents aged 15 to 19 years in England and Wales showed an overall decrease in accidental deaths from 2001 to 2010. However, rates of accidental poisoning and hanging increased during the same period. These findings highlight the importance of examining specific mechanisms of injury even when overall mortality rates decline.An analysis of deaths among Chinese children younger than 4 years showed that accidental injuries accounted for 10% of reported deaths. Asphyxia, drowning, and traffic-related injuries were the leading causes, followed by poisoning and falls. Australian studies showed an increase in heroin-related deaths from 2001 to 2012. Approximately 2-thirds of these deaths occurred among men aged 15 to 74 years. Unintentional opioid-related deaths increased during this period, whereas intentional opioid-related deaths remained stable.

Reports from Turkey described a series of accidental hangings among children. These deaths most commonly involved scarf-like materials wrapped around cradles to prevent infants from falling. This finding emphasizes the importance of recognizing culturally specific injury risks when developing prevention strategies.

Pediatrics

Sudden unexpected infant death (SUID) is an umbrella term that includes sudden infant death syndrome, accidental suffocation and strangulation in bed, and other deaths from unknown causes. SUID has remained a leading cause of infant death in the United States, including as recently as 2017. These deaths most commonly occur between the second and fourth months after birth.

Risk factors for SUID include a nonsupine sleeping position, bed sharing with an adult, maternal tobacco use during pregnancy, late or absent prenatal care, preterm birth, low birth weight, and loose objects such as pillows or blankets in the crib. Secondhand smoke exposure is also associated with an increased risk of SUID, although maternal tobacco use during pregnancy confers a greater risk. Results from an 8-year study of pediatric deaths in South Dakota beginning in 2000 showed that accidental suffocation was the most common cause of infant death.

Measures that may lower the risk of SUID include placing infants supine on a firm sleep surface, keeping the sleep area free of soft objects such as pillows and bumper pads, and sharing a room without sharing a bed. Breastfeeding, pacifier use at bedtime, and routine vaccination against tetanus, diphtheria, and pertussis may also reduce risk. Maintaining an appropriate room temperature and avoiding overheating are additional preventive measures. Home cardiorespiratory monitors have not been shown to prevent SUID.[7]

Clinical Significance

Prevention Strategies

Clinicians can help prevent fatal accidents by addressing the pain-control needs of patients with chronic pain and carefully evaluating the use of opioids. Results from a study of 816 opioid overdose cases in Colorado showed that the risk of overdose was positively associated with receiving prescriptions from multiple clinicians and filling prescriptions at multiple pharmacies and negatively associated with naltrexone use. Results from the same study showed an increased risk of overdose when methadone was prescribed as a first-line opioid and an even greater risk when another opioid was discontinued and replaced with methadone. However, international studies have reported conflicting findings, with some showing decreased overall overdose mortality associated with prescribed methadone. These differences may reflect variations in the clinical indication, patient population, and treatment setting. Clinicians should recognize opioid use disorder and refer patients for evidence-based treatment when appropriate.[8][9][10]

In pediatrics, education regarding safe sleep practices for newborns can reduce the risk of sudden unexpected infant death. Placing newborns in a supine sleeping position has produced the most substantial reduction in mortality. Clinicians should also counsel pregnant patients regarding tobacco cessation to reduce the risk of infant death. Clinicians should routinely screen for safety practices and encourage the use of bicycle helmets, seat belts, and age-appropriate child restraint systems in motor vehicles.

Pregnancy

Results from a 1-year review of deaths among pregnant women in Clark County, Nevada, showed that accidental deaths accounted for 38% of deaths categorized by the authors as unnatural. Motor vehicle trauma was the most common cause, followed by overdose and drowning. An analysis of women who were pregnant or had been pregnant within the previous year in North Carolina showed an increase in prescription opioid-related deaths from 1996 to 2007. A similar trend was not observed for cocaine- or heroin-related deaths in this population.

Autoerotic Activity

Numerous case reports and case series have described accidental deaths associated with autoerotic activity, most commonly due to asphyxiation. These cases have involved males almost exclusively. Other reported causes of accidental death in this setting include subarachnoid hemorrhage, left-sided heart failure, hypothermia, and drowning. Less common mechanisms have also been reported, including fatal air embolism after pressurized air was introduced into the urethra.

Many fatal injuries are preventable through public education and coordinated interventions from an interprofessional healthcare team. Clinicians, nurses, pharmacists, and other healthcare professionals should educate patients regarding the safe use and storage of prescription medications, the risks associated with illicit drug use, the importance of wearing seat belts, and safe firearm storage practices. The healthcare team should also assess individual risk factors and reinforce practical prevention strategies during routine clinical encounters. Limited adherence to recommended safety measures contributes to the continued burden of preventable accidental deaths.[11]