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Automated driving systems (ADS) have the potential for improving safety but also pose the risk of extending the transportation system beyond its edge conditions , beyond the operating conditions (operational design domain (ODD)) under which a given ADS or feature thereof is specifically designed to function. The ODD itself is a function of the known bounds and the unknown bounds of operation. The known bounds are those defined by vehicle designers; the unknown bounds arise based on a person operating the system outside the assumptions on which the vehicle was built. The process of identifying and mitigating risk of possible failures at the edge conditions is a cornerstone of systems safety engineering (SSE); however, SSE practitioners may not always account for the assumptions on which their risk mitigation resolutions are based. This is a particularly critical issue with the algorithms developed for highly automated vehicles (HAVs). The injury prevention community, engineers and designers must recognise that automation has introduced a fundamental shift in transportation safety and requires a new paradigm for transportation epidemiology and safety science that incorporates what edge conditions exist and how they may incite failure. Towards providing a foundational organising framework for the injury prevention community to engage with HAV development, we propose a blending of two classic safety models: the Swiss Cheese Model, which is focused on safety layers and redundancy, and the Haddon Matrix, which identifies actors and their responsibilities before, during and after an event., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Driver error and inadequate skill are common critical reasons for novice teen driver crashes, yet few validated, standardised assessments of teen driving skills exist. The purpose of this study is to evaluate the construct and criterion validity of a newly developed Simulated Driving Assessment (SDA) for novice teen drivers., Methods: The SDA's 35 min simulated drive incorporates 22 variations of the most common teen driver crash configurations. Driving performance was compared for 21 inexperienced teens (age 16-17 years, provisional license ≤90 days) and 17 experienced adults (age 25-50 years, license ≥5 years, drove ≥100 miles per week, no collisions or moving violations ≤3 years). SDA driving performance (Error Score) was based on driving safety measures derived from simulator and eye-tracking data. Negative driving outcomes included simulated collisions or run-off-the-road incidents. A professional driving evaluator/instructor (DEI Score) reviewed videos of SDA performance., Results: The SDA demonstrated construct validity: (1) teens had a higher Error Score than adults (30 vs. 13, p=0.02); (2) For each additional error committed, the RR of a participant's propensity for a simulated negative driving outcome increased by 8% (95% CI 1.05 to 1.10, p<0.01). The SDA-demonstrated criterion validity: Error Score was correlated with DEI Score (r=-0.66, p<0.001)., Conclusions: This study supports the concept of validated simulated driving tests like the SDA to assess novice driver skill in complex and hazardous driving scenarios. The SDA, as a standard protocol to evaluate teen driver performance, has the potential to facilitate screening and assessment of teen driving readiness and could be used to guide targeted skill training., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Inexperienced, less-skilled driving characterises many newly licensed drivers and contributes to high crash rates. A randomised trial of TeenDrivingPlan (TDP), a new learner driver phase internet-based intervention, demonstrated effectiveness in improving safety relevant, on-road driving behaviour, primarily through greater driving practice diversity. To inform future learner driver interventions, this analysis examined TDP use and its association with practice diversity., Design: Posthoc analysis of data from teen/parent dyads (n=107), enrolled early in learner phase and assigned to treatment arm in randomised trial., Methods: Inserted software beacons captured TDP use data. Electronic surveys completed by parents and teens assessed diversity of practice driving and TDP usability ratings at 24 weeks (end of study period)., Results: Most families (84%) used TDP early in the learner period; however, the number of TDP sessions in the first week was three times higher among dyads who achieved greater practice diversity than those with less. By week five many families still engaged with TDP, but differences in TDP use could not be detected between families with high versus low practice diversity. Usability was not a major issue for this sample based on largely positive user ratings., Conclusions: An engaging internet-based intervention, such as TDP, can support families in achieving high practice diversity. Future learner driver interventions should provide important information early in the learner period when engagement is greatest, encourage continued learning as part of logging practice drives, and incorporate monitoring software for further personalisation to meet family needs., Trial Registration: NCT01498575., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In order to test stereotypes that mothers are more safety conscious than fathers, this study aimed to explore differences in restraint patterns, front-row seating and injury for children in crashes when driven by fathers versus mothers, both when driving alone and with other adults. From 15 January 2003 to 30 November 2007, data were collected via insurance claims records and telephone surveys on a weighted sample of 10,715 child passengers in crashes. When riding with children and no other adults, father drivers in crashes were more likely than mother drivers to transport children <9 years old unrestrained or suboptimally restrained (35.0% vs 26.1%, p=0.001) and to seat children <13 years old in the front row (23.7% vs 14.3%, p<0.001). For children <16 years, no statistically significant difference in injury risk was noted for father versus mother drivers, regardless of adult passenger presence. Further improvements in child passenger safety might be gained with campaigns directed at both fathers and mothers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: Child fatality review (CFR) is the systematic, interdisciplinary, multi-agency examination of paediatric deaths. While CFR findings may influence policies and reduce preventable fatalities, limited resources challenge accurate CFR data collection and prevention recommendations. Therefore, using technology to improve efficiency of reviews and access to remote participants could enhance the CFR experience. This project aimed to adapt a previously developed collaborative web-based appliance for remote, secure, collaborative review of crash investigations for use with CFR., Methods: The user-centred design and evaluation process included: (1) key informant interviews and visits to CFR sessions to determine current practices, (2) an anonymous, qualitative, internet-based survey of 64 Pennsylvania CFR team leaders, (3) redesign and adaptation of the Telecenter appliance based on survey results and team feedback and (4) pilot-testing of the adapted Telecenter application at an actual local CFR., Results: The qualitative informant interviews identified facilitators and barriers for adoption of the Telecenter. Facilitators included: team member training, improved communication and collaboration, more efficient reviews, and enhanced preventive efforts. Barriers identified included: concern for confidentiality and security, concern about accepting a novel CFR method, low interest in using technology, cost and maintenance. The survey of CFR team leaders identified themes for improving CFR team functioning including the need for evidence-based prevention resources, increased team training and efficient information gathering. The Telecenter was redesigned and adapted based on the information gathered and was successfully piloted for use with CFR., Conclusions: Telecenter met the design goal to improve information dissemination and identification of fatality prevention strategies for CFR.

Background: Increased belt-positioning booster seat (BPB) awareness and access have led to increased use in the USA. Although transportation in Beijing is rapidly becoming 'motorised', Beijing's population has limited awareness of or access to BPBs., Objective: To explore the efficacy and acceptability of using a US-developed BPB use promotion intervention in Beijing., Design: Methods were adapted from a previously executed US-based study involving parents of 3-8-year old children. Focus groups (five groups, 71 participants) elicited behavioural antecedents to BPB use and reactions to video interventions promoting BPB use: a Chinese-produced instructional video and an English-language (dubbed into Mandarin) video that delivered concrete, theoretically driven messages through a personal story. Immediately after the focus groups, participants were provided with education and a free BPB. Participants were contacted 6&emsp14;weeks later via telephone about use, knowledge and attitudes., Results: Chinese parents saw safety as the most important benefit of BPB use; lack of accurate knowledge about and access to BPBs were parents' most prevalent barriers. Chinese participants described the videos as persuasive and instructional. At 6&emsp14;weeks, participants remembered the messages of the English-language video, and reported BPB use increased from a baseline of 15.5% to 85.5%., Conclusions: This study shows the possibility of exporting US-designed prevention interventions dubbed into Mandarin without the need to alter their original context (in this case, an African American family in a US setting) into a Chinese context. Successful cultural translation involved ensuring that the behavioural antecedents targeted in the intervention (eg, barriers and benefits) were of relevance to the Chinese population.

Behavioural science when combined with engineering, epidemiology and other disciplines creates a full picture of the often fragmented injury puzzle and informs comprehensive solutions. To assist efforts to include behavioural science in injury prevention strategies, this paper presents a methodological tutorial that aims to introduce best practices in behavioural intervention development and testing to injury professionals new to behavioural science. This tutorial attempts to bridge research to practice through the presentation of a practical, systematic, six-step approach that borrows from established frameworks in health promotion and disease prevention. Central to the approach is the creation of a programme theory that links a theoretically grounded, empirically tested behaviour change model to intervention components and their evaluation. Serving as a compass, a programme theory allows for systematic focusing of resources on the likely most potent behavioural intervention components and directs evaluation of intervention impact and implementation. For illustration, the six-step approach is applied to the creation of a new peer-to-peer campaign, Ride Like a Friend/Drive Like You Care, to promote safe teen driver and passenger behaviours.

Objective: To understand definitions of the phrases "good driver" and "safe driver" among teen pre-drivers and early drivers in order to appropriately tailor messages about driving safety., Design: Qualitative study using freelisting, an anthropological research technique, to explore nuances in the ways that teens define a good driver and a safe driver, Setting: Classes in six high schools each in a different state in the USA., Subjects: 193 adolescent pre-drivers and early drivers, aged 15-17., Main Outcome Measures: Meaning of the phrase good driver and safe driver was identified for subgroups of adolescents., Results: Teen pre-drivers and early drivers define a good driver and a safe driver as one who is cautious, alert, responsible, does not speed, obeys the law, uses seatbelts, and concentrates. There are subtle and potentially important differences in the way that subgroups define a good driver and a safe driver., Conclusions: Injury prevention experts need to attend closely to the implicit meanings that teens attach to everyday terms. Freelisting is a method that identifies perceptions about the meaning of health communication messages and suggests differences in meaning among subgroups.

Several international jurisdictions allow family exemptions to graduated driver licensing passenger restrictions. The objective of this research was to examine differences in injury risk to US child passengers in crashes involving sibling versus non-sibling teen drivers, and to compare outcomes with crashes involving adult drivers. Insurance claim and telephone survey data were collected on 16 233 child passengers (representing 289 329 children) in 17 US jurisdictions. There was a trend toward higher restraint non-use by child passengers in the non-sibling group than in the sibling group (9.6% vs 4.7%; p = 0.08). Children in the sibling group had a 40% lower risk of injury than those in the non-sibling group (adjusted OR 0.60, 95% CI 0.40 to 0.90); however, injury risk was higher in the sibling group than in children traveling with adults (adjusted OR 1.57, 95% CI 1.09 to 2.26). Child passengers riding with sibling teen drivers may be safer than those riding with non-sibling teens, but not as safe as those riding with adult drivers.

Objective: To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED)., Methods: The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained., Results: The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered., Conclusions: Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.

Supplement Editor, Dr Flaura K Winston, and Co-Editor, Dr Teresa Senserrick, introduce 10 papers covering the current science of safe driving among adolescents from the varied viewpoints of an international panel of experts. This Expert Panel, convened by the Center for Injury Research and Prevention (formerly TraumaLink) at the Children's Hospital of Philadelphia and State Farm Insurance Companies(R), working jointly on the Youthful Driver Research Initiative, represents a wide range of expertise, thereby providing a broad understanding of driving, adolescence, and adolescent driving.

Objectives: To describe the trip characteristics of vehicle crashes involving children, and to examine the effect of situational factors on front row seating or inappropriate restraint for young children., Methods: A cross sectional study was conducted on children <16 years in crashes of insured vehicles in 15 US states, with data collected using insurance claims records and a telephone interview. A descriptive analysis of the characteristics of vehicle crashes involving children was performed. Multivariate Poisson regression was used to identify situational factors associated with inappropriate restraint or front row seating., Results: These data suggest that children were traveling in vehicles involved in crashes that occurred under usual driving circumstances-that is, closer to home (60%), on a local road (56%), during normal daytime hours (71%), within areas with relatively lower posted speed limits (76%). Compared with children involved in morning crashes, those in daytime crashes (RR = 1.65, 95% CI 1.13 to 2.49) or in night-time crashes (RR = 1.63, 95% CI 1.09 to 2.67) were more likely to be sitting in the front seat. Children involved in night-time crashes were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.01 to 1.22) than those in daytime crashes. Children riding with two or more additional passengers were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.02 to 1.27) than those with no other passengers., Conclusions: Educational initiatives should aim to increase the perception that parents have about the potential crash risk of everyday trips. Some situational characteristics of trips were associated with inappropriate restraint and front row seating behaviors for young children.

Objectives: The first aim was to examine the relationship between driver's age (novice teens, older teens, and adults) and child passenger's restraint status, front row seating, and injury risk. The second aim was to explore whether there was an excess injury risk to child passengers in teen crashes compared to those in adult crashes by examining the contributing factors., Methods: A cross sectional study involving telephone interviews with insured drivers in a probability sample of 12 163 crashes involving 19 111 children was conducted. Sequential logistic regressions were employed., Results: Among child passengers aged 4-8, appropriate restraint was <1% for novice teens, 4.5% for older teens, and 23.6% for adults. Front row seating for children <13 years was more common in the novice teen group (26.8%) than in the other two groups. Compared with children riding with adults, those with both teen groups experienced excess injury risk. After adjusting for crash severity, there was a 43% reduction in the odds ratio (OR) for novice teens (OR 1.58, 95% confidence interval (CI) 1.14 to 2.19) and a 24% reduction for older teens (OR 2.15, 95% CI 1.42 to 3.26). After adjusting for vehicle type, child's restraint status and front row seating, there was a further 19% reduction in the OR for novice teens (OR 1.37, 95% CI 1.00 to 1.88) and a further 13% reduction for older teens (OR 1.74, 95% CI 1.14 to 2.66)., Conclusion: These findings suggest ways in which graduated driver licensing laws may be further enhanced to better protect child passengers from the excess injury risk associated with teen crashes.

Objectives: To explore the immediate pre-crash activities and the routine traffic exposure (street crossing and play) in a sample of urban children struck by automobiles. In particular, the traffic exposure of children who were struck while playing was compared with that of those struck while crossing streets., Design: Cross sectional survey., Setting: Urban pediatric emergency department., Patients: A total of 139 children ages 4-15 years evaluated for acute injuries resulting from pedestrian-motor vehicle collisions during a 14 month period., Main Outcome Measures: Sites of outdoor play, daily time in outdoor play, weekly number of street crossings, pre-crash circumstance (play v walking)., Results: Altogether 39% of the children routinely used the street and 64% routinely used the sidewalks as play areas. The median number of street crossings per week per child was 27. There were no differences in exposures for the 29% who were hit while playing compared with the 71% who were hit while walking. Although 84% of the children walked to or from school at least one day per week, only 15% of the children were struck while on the school walking trip. The remainder were injured either while playing outdoors or while walking to other places., Conclusions: Urban children who are victims of pedestrian crashes have a high level of traffic exposure from a variety of circumstances related to their routine outdoor playing and street crossing activities. The distributions of traffic exposures were similar across the sample, indicating that the sample as a whole had high traffic exposure, regardless of the children's activity preceding the crash. Future pedestrian injury programs should address the pervasive nature of children's exposure to traffic during their routine outdoor activities.

Objective: The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records., Methods: A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record., Results: Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented: identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event., Conclusions: Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.

Objective: To describe several aspects of booster seat use and misuse in a sample of children attending child safety seat clinics., Methods: Booster seat practices were assessed at 76 child safety seat clinics held between April 1997 and January 1999 in Pennsylvania and southern New Jersey. At each assessment, a child passenger safety team evaluated the booster seat and identified modes of misuse., Results: Altogether 227 booster seats were observed. Sixty eight per cent (68%) of shield boosters and 20% of belt positioning boosters were misused. Thirty two per cent of the children using a shield booster weighed more than 40 lb (18.1 kg); 68% of children in shield boosters and 63% in belt positioning boosters weighed less than 40 lb., Conclusion: This study identified a relatively high rate of booster seat misuse. Shield boosters were more likely to be misused than belt positioning booster seats. Significant numbers of children weighing more than 40 lb were using possibly dangerous shield boosters. The majority of children in this study were less than 40 lb. In this weight range, a convertible child restraint system provides better protection than a booster seat. Booster seat use should only be initiated once the child has completely outgrown their convertible child restraint system.

Objective: To determine the extent to which child restraint system (CRS) misuse can be evaluated by parental survey., Methods: A cross sectional survey was conducted at eight CRS clinics from May to October, 1998. Before CRS inspection, parents were administered a structured interview to identify distinct characteristics of restraint use and misuse. After the interview, a certified child passenger safety technician team independently evaluated the restraint system and identified specific modes of misuse. Parent descriptions of CRS use were compared with observations of the technician and the degree of agreement between the two was assessed for several specific attributes of use., Results: A total of 100 children restrained in convertible CRSs were included in the study. Parents were able to accurately report several aspects of child restraint use-in particular, the attachment and fit of the CRS, the use of the harness clip, and the CRS incline. Parents were less accurate in their characterization of the fit of the child in the CRS. For nearly every item assessed, parents were more accurate in their description of correct compared with incorrect use., Conclusions: Interview tools can be developed that enable parents to describe aspects of CRS use and that screen for correct CRS use. These tools could be administered by telephone to obtain a more representative estimate of the prevalence of CRS misuse or to screen for CRS misuse. This screening would assist in targeting time consuming and costly CRS clinics to those parents who need them the most.