System analysis of clinical incidents: The London Protocol 2024

Summary

The London Protocol is a tool for analysing errors and incidents, using a systems approach to understand the underlying causes and prevent incidents from recurring. It was originally published in 2004. Attached, you will find the updated 2024 version of the Protocol.

Content

The investigation of incidents and accidents, together with subsequent reflection and action, is the foundation of safety management in every safety critical industry. Incident investigation is of course only one component of safety management but nevertheless an essential one. When conducted thoughtfully, incident analysis facilitates learning, safety improvement and supports the development of a proactive safety culture. Reflections and analysis of positive outcomes can also be valuable, particularly when safety was threatened and then recovered.

The London Protocol is a method of analysing incidents in healthcare which provides a window on the healthcare system illuminating its strengths, vulnerabilities and capacity for change. The essential idea is that much can be learned about the wider healthcare system from the close examination of a single patient journey.

Since the publication of the London Protocol in 2004, healthcare has evolved and changed which means that the investigation of safety incidents must be adapted in a number of ways that are discussed below. The most important change is that patient and families are increasingly engaged in their own care and that their contribution is critical to many, if not most, safety investigations. The authors have emphasised that the priority in any investigation or analysis is to look after the patient, family, and staff who are affected. We need to support them and address their needs before engaging them directly in the review and analysis. This new version of the London Protocol is not designed to address this critical issue in detail, but provide some directions and guidance to support this process.