1. Introduction
ccidents are one of the leading causes of non-communicable diseases [1, 2], which are no longer considered as a random phenomenon but are a price that humans have to pay for the advancement of technology. Accidents, as the second leading cause of disability, can lead to physical and mental disorders and, in severe cases, even death [3]. Traffic accidents are the eighth leading cause of death globally, and the first leading cause of death in the age group of 15-29 years [4]. 
According to the World Health Organization, the number of deaths due to traffic accidents will increase by 80% from 2000 to 2020 [5]. According to studies, about 9 million accidents occur every year, and accidents are among the leading causes of hospitalization and death. According to published statistics, various injuries caused by accidents account for 3% of all visits to medical centers in Iran [6]. Every year, more than 5 million people in the world die due to injuries caused by accidents, and tens of millions of people go to emergency departments for reasons such as accidents, drownings, falls, violence, electric shocks, bites, suicides, etc. Besides hurting people’s health, traffic accidents incur costs related to care and treatment and rehabilitation needs and have a psychological effect on people [7]. 
Vehicle accidents are considered a very serious issue and are inevitable consequences of traffic and road transport [5]. Motorcycle crashes account for a significant number of all accidents worldwide. More than 51% of traffic accidents that lead to death or hospitalization are related to motorcyclists in Iran [8, 9]. 
In a few studies, Pareto charts have been used to identify and prioritize problems in various contexts. Pareto chart (Pareto analysis) is a way to manage errors and shortcomings to focus on problem solving. This chart is based on the work of the 19th-century economist Wilfredo Pareto. Joseph M. Juran generalized Pareto’s principle by stating that 80% of a company’s problems are the result of only 20% of the causes [10]. Pareto chart is used to identify the issues and topics that have caused the highest share of problems. The primary purpose of using a Pareto chart is to create a system that can automatically audit and modify. In this study, the frequency and causes of accidents registered in Gonabad City’s Medical Emergency and Accident Management Center in 2018 based on the Pareto chart were investigated.
2. Materials and Methods
This research was a cross-sectional descriptive study in which all accidents registered in Gonabad City’s Medical Emergency and Accident Management Center in 2018 were examined based on the Pareto chart. This chart represents frequency distribution for descriptive data, which are classified by groups. The horizontal axis of this chart shows the categories, and its vertical axis shows the frequency or percentage of observations of each category. This method determines the area in which the most problems (80%) are located. The Pareto chart identifies essential factors leading to a “defect” or “defect in a process” [11]. 
After determining the frequency of influential factors, a chart is drawn based on their frequencies and percentages of inclusion. To obtain frequencies, it is necessary to prepare an accident register form based on the required information and analyze them. Although all actions and calculations can be done manually, using the right software increases the speed and accuracy of the job. The two most widely used applications in this field are SPSS and Minitab.
In this study, information about all accidents in 2018 was examined. These variables included the number of accidents, causes of the accidents, gender and age of victims, time of the accident, marital status, location of the accident, injured body part, drugs used in transport, and non-transport accidents. They were collected and then analyzed in Minitab16, SPSS v. 18, and EXCEL V. 2010 applications.
3. Results
According to the present study results, a total of 12281 accidents and medical emergencies were recorded in Gonabad City in 2018, of which 4174 were urban, and 8107 were road accidents. Also, the results of accident investigation by the “type of accident” are shown in Figure 1.  As the results show, “chemical and electrical burns” with one case had the lowest number of accidents, and “falls from heights” with 542 cases (46%) and “collision with mechanical force” with 222 cases (19%) had the highest number of accidents. The results of investigating traffic accidents by the “condition of injured person” are shown in Figure 2, and by the “vehicle type” in Figure 3.  According to Figure 4, the results showed that the highest number of accidents occurred in September and April, and the lowest number of accidents occurred in July and May. The results of the investigation of accidents by age of the injured are shown in Figure 5.  The results also showed that most people referred to the emergency medical center were related to “accident” with 1903 cases (15.5%) and then to “collision with mechanical force” with 1616 cases (13.1%). “Fire” with one case (0.008%) had the lowest number of accidents (Figure 6).  Also, the number of accidents in males was higher than females (55.3% and 44.7%, respectively).
4. Discussion
According to the results of this study, more than 60% of emergencies were related to the “fall from heights” and “collisions with mechanical force”, and the least to “chemical burns and electrical burns”. Also, most of the complaints of people referring to the emergency medical centers were related to “accidents”. The results of the study of Beheshti et al. which was conducted with the same title but from 2013 to 2016, were also consistent with the results of the present study [12]. In the study of Khatibi et al. (2007), most cases were related to “traffic accidents” (42%) and the least to “electric shocks” (0.2%) [3]. Also, in Hamid Souri’s study (2001), the epidemiology of accidents in children referred to the emergency department of Ahvaz hospitals proved that “trauma caused by various objects” (37.2%), “falls from heights” (22.8%), and “traffic accidents” (10.6%) were the leading causes of the injuries [13].
In the study of Koohpaei et al. in Gonabad City (2014-2016), “traffic accidents” accounted for 17.61% and “heart accidents” for 10.92% of the total number of accidents [14]. According to the present study results and its comparison with the results of the Koohpaei et al. study, traffic accidents have increased significantly in recent years, the essential type of which is “falls from heights”. In the study of Masoud Mohammadi et al. (2016), both men and women had the highest frequency. The percentage of accidents were as follows: “car accident” with 758 cases (30.9%), “violence” with 323 cases (11.9%), and “suicide” with 121 cases (10.9%) [6]. 
In the study of Ghahraman Mahmoudi et al. (2013), most deaths were related to “road accidents”, and after “traffic accidents”, the “falls from heights” had the highest rate of injury, which is consistent with the results of the present study [7]. In the study of Ahmadpour et al. (2009) in Qazvin City, Iran, the highest rate of accidents was related to traffic accidents (38.1%), and the lowest rate to suicide (0.8%) [15]. All of the above study results are consistent with the present study results, which accounted for the highest rate of traffic accidents.
In the present study, drivers accounted for 55%, occupants 40%, and pedestrians 8% of the victims of accidents. In the study of Seyed Saeed Hashemi Nazari et al. (2012), the situation of people who died during the accident showed that the incidence of deaths were as follows: pedestrians 324 cases (24.36%), passengers 419 cases (31.5%), drivers 569 cases (42.78%), and unknown 18 cases (1.35%) [16]. Also, in the study of Payman Asadi et al. the most injured in traffic accidents were motorcyclists and car occupants [17]. In the study of Seyed Saeed Hashemi Nazari et al. (2012), the results showed that the incidence of mortality in drivers (42.78%) is the highest [16]. The results of all these studies confirm the results of the present study in the sense that drivers have the highest number of injured.
The highest rate of accidents is related to motorcycles (more than 45%), and then light vehicles (more than 45%), which is consistent with the study results of Payman Asadi and associates. Also, in the study of Seyed Saeed Hashemi Nazari et al. 47.9% of the deceased used cars and vans, 43.6% motorcycles and bicycles, and 8.5% heavy vehicles [16]. Kazem Alizadeh Barzian, in his study, showed that out of 55108 accidents resulting in injuries in Behbahan City, Iran, 48.5% are related to traffic accidents, the highest of which is related to motorcyclists (58.8%) [18]. 
Teaching traffic rules through public media has a significant role in increasing public awareness. Awareness of people about the importance of observing safety regulations while driving and improving the quality of streets effectively reduces accidents. In the present study, the rate of road accidents was higher than the street (urban) accidents (65% and 35%, respectively). This finding could be due to non-compliance with the speed limit on suburban roads, lack of warning signs in accident hotspots, insufficient rest before driving, continuous driving over long distances, etc. The number of accidents can be reduced by educating preventive measures, paying more attention to road safety, and increasing police control. 
In the study of traffic accidents in Ethiopia (2008), the main factors influencing the number, causes, and possible interventions of accidents were poor road network, lack of awareness about road traffic safety, mixed traffic flow system, lack of rules to put pressure on drivers, unsuitable vehicle conditions, poor emergency medical services, and the absence of compulsory insurance law on traffic accidents [19]. Also, in the study of Ansari et al. (2000), the results showed that more than 65% of accidents were due to vehicles traveling too fast or drivers disobeying traffic signs [20]. In Ahmadpour’s study, the number of accidents on suburban and urban roads was equal (18%), which was mainly related to automobiles (20.6%) [15]. In Asadi’s study, most accidents (53.1%) were on suburban roads [17].
In the present study, the number of accidents that occurred in September and April was the highest. In Hashemi Nazari’s study (2012), a total of 34.43% of deaths due to traffic accidents occurred in summer, 26.69% in spring, 23.23% in autumn, and 15.64% in winter, and the highest incidence and frequency of death was observed in July [16]. In the study of Khatibi and Zarei, the most accidents occurred in summer, September [3, 21], and in the study of Koohpaei et al. between 2014 and 2016, the highest accident rate was in spring [14]. Also, in Asadi’s research, most accidents were in summer [17]. All these studies are consistent with the present study, which could be due to holidays and increased travel in this season. 
In the present study, the age group of 16 to 20 years had the highest rate of accidents, and the number of accidents was higher in men than women. According to the study of Khatibi et al. 73.7% of the accidents were related to men and 26.3% to women. Also, most of the accidents were related to 15 to 20 years old people [3]. According to Koohpaei et al.’s study, between 2014 and 2016, the highest accident rate was in the ages of 0 to 10 years [14]. Based on Zarei et al. study, the highest number of accidents (60.93%) was related to men [21], all of which are similar to the present study results.
5. Conclusion
In this study, all accidents in 2018 were reviewed, and the existing data reference was valid, which is one of the strong points of this study and can help city managers for future planning to prevent accidents. However, due to the lack of complete records of some accidents, further studies can be done in this area. The results of the present study showed that “traffic accidents” and “falls from heights” are the most important emergencies that harm society. By focusing and assigning priorities on controlling these accidents, health and safety policymakers can reduce a large portion of society’s accidents.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Gonabad University of Medical Sciences (code: IR.GMU.REC.1398.008). 

Funding
This study has been registered as a Research Project (Ethics Code: IR.GMU.REC.1398.008) in Gonabad University of Medical Sciences, Vice-Chancellor for Research. 

Authors' contributions
Supervision: Mohammad Hossein Beheshti, Mojtaba Emkani, Amin Zamani, Akram Tabrizi and Mostafa Jafari; Conceptualization: Mohammad Hossein Beheshti and Mostafa Jafari; Data analysis: Mohammad Hossein Beheshti, Akram Tabrizi and Mostafa Jafari; Writing – original draft: Mohammad Hossein Beheshti, Mojtaba Emkani and Amin Zamani, Mostafa Jafari, and Akram Tabrizi; Data collection: Amin Zamani; Methodology: Mojtaba Emkani.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors express their gratitude and appreciation to Gonabad University of Medical Sciences Vice-Chancellor for Research.


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