Systems analysis of clinical incidents: development of a new edition of the London Protocol (22 February 2025)

Summary

The investigation of incidents and accidents, together with subsequent reflection and action, is an essential component of safety management in every safety-critical industry, including healthcare. A number of formal methods of incident analysis were developed in the early days of risk management and patient safety, including the London Protocol which was published in 2004.

In this paper, the author describe the development of a new edition of the London Protocol. They explain the need for a revised and expanded version of the London Protocol, addressing both the changes in healthcare in the last two decades and what has been learnt from the experience of incident analysis across the world.