Centre for Patient Safety and Service Quality (CPSSQ)

Systems Analysis of Clinical Incidents: The London Protocol

Background

The London Protocol is the revised and updated version of our original ‘Protocol for the Investigation and Analysis of Clinical Incidents’ first published in 1999 (Vincent et al, BMJ 1998; Vincent et al, BMJ 2000; Vincent, NEJM 2003).

The protocol outlined a process of incident investigation and analysis for use by clinicians, risk and patient safety managers, researchers and others wishing to reflect and learn from clinical incidents. This approach has now been refined and developed in the light of experience and research into incident investigation both within and outside healthcare. It is designed to be a structured process of reflection on incidents providing a ‘window on the healthcare system’ (Vincent, QSHC 2004) which can be adapted for use in many contexts and used either quickly for education and training or in substantial investigations of serious incidents.

Downloads

The London protocol is free to download and available in a number of languages:

 

Selected bibliography

Academic papers describing development and application of the London Protocol are also available:

  • Bellandi T, Albolino S, Tartaglia R, Filipponi F. The unintended transplantation of three organs from a positive HIV donor: case report of the analysis of the adverse event occured in 2007 in a Regional Healthcare Service in Italy”. Transplant Proc. 2010 Jul-Aug;42(6):2187-9 Pubmed
  • Garnerin P, Schiffer E, Van Gessel E, Clergue F. Analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit. BJA: British Journal of Anaesthesia 2002; 89(4):633-635. Pubmed
  • Garnerin P, Huchet-Belouard A, Diby M, Clergue F. Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Acta Anaesthesiol Scand 2006; 50(9):1114-1119. Pubmed
  • Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Strange P, Tizzard A. Comment enqueter sur des incidents cliniques et les analyses: protocole de l'unite des risques cliniques et de l'association de las gestion du contentieux et des risques. Ann Fr Anesth Reanim 2002; 21:509-516. INIST
  • Rogers S. A structured approach for the investigation of clinical incidents in health care: application in a general practice setting. British Journal of Medical Practice 2002; 52(Suppl):S30-S32. Pubmed
  • Stanhope N, Vincent CA, Adams S, O'Connor AM, Beard RW. Applying human factors methods to clinical risk management in obstetrics. British Journal of Obstetrics and Gynaecology 1997; 104(11):1225-1232. Pubmed
  • Taylor-Adams S, Vincent CA, Stanhope N. Applying human factors methods to the investigation and analysis of clinical adverse events. Safety Science 1999; 31(2):143-159. INIST
  • Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. British Medical Journal 1998; 316(7138):1154-1157. Pubmed
  • Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P et al. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. British Medical Journal 2000; 320(7237):777-781. Pubmed
  • Vincent C. Understanding and responding to adverse events. New England Journal of Medicine 2003; 348(11):1051-1056. Pubmed
  • Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Quality and Safety in Health Care 2004; 13(4):242-243. Pubmed
  • Woloshynowych M, Roger S, Taylor-Adams S, Vincent C. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess 2005; 9(19):1-158. Monograph

Contact

Please contact Prof Charles Vincent for further information on the London Protocol.

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