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Unintentional injuries are the leading cause of death in children and youth all over the world. Presentation at a health facility when injured may provide a key opportunity to impart safety education counselling, but should be evaluated for effectiveness due to time and cost implications. METHODS: A systematic review was conducted to assess whether injury interventions based in the clinical setting are effective in reducing injury and changing safety behaviours in children and youth. Studies were included in the systematic review if: 1) the intervention was designed to prevent unintentional injuries to children or adolescents under 20 years of age; 2) the intervention was delivered in a "clinical setting," such as a physician’s office, a clinic, an emergency department, or a hospital; 3) participants were assigned randomly to the intervention and control groups; and 4) the study collected empirical data on injuries or safety practices (e.g. seatbelt use). Databases searched included the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Dissertation Abstracts. RESULTS: Of the 21 randomised controlled trials that met the inclusion criteria, the majority assessed the effect of an intervention on safety behaviours, rather than on injury occurrence. Outcomes assessed included: motor vehicle restraint use; bicycle helmet use; safe tap water temperature; smoke alarm ownership; and a variety of safety practices designed to protect young children from injuries in the home (such as safe storage of cleaning materials and medication). Results of interventions varied by outcome assessed, with motor vehicle restrain use, bicycle helmet purchase, likelihood of having safe hot water temperature and owning a smoke alarm all improved. Home safety improved least in response to counselling. Trials that had the greatest effect on safety practices used a combination of education, demonstrations, provision of free or subsidised safety devices (such as smoke alarms, cycle helmets), and repeated reinforcement of the safety messages. CONCLUSIONS: Counselling alone is unlikely to alter behaviour in the long term. Despite their importance as causes of injury, no trials evaluating clinical interventions designed to prevent motorcycle, pedestrian, drowning, or firearm injuries were identified, and only one designed to prevent alcohol-related injuries was identified.