Systems analysis of clinical incidents: the London protocol

Abstract

The London Protocol is the revised and updated version of our original Protocol for the Investigation and Analysis of Clinical Incidents. 1 The protocol outlined a process of incident investigation and analysis developed in a research context, which was adapted for practical use by risk managers and others trained in incident investigation. This approach has now been refined and developed in the light of experience and research into incident investigation both within and outside healthcare."The purpose of the protocol is to ensure a comprehensive and thoughtful investigation and analysis of an incident, going beyond the more usual identification of fault and blame."The purpose of the protocol is to ensure a comprehensive and thoughtful investigation and analysis of an incident, going beyond the more usual identification of fault and blame. A structured process of reflection is generally more successful than either casual brainstorming or the suspiciously quick assessments of 'experts'. The approach described does not supplant clinical expertise or deny the importance of the reflections of individual clinicians on an incident. Rather the aim is to utilize clinical experience and 211CLINICAL RISK (2004) 10, 211-220

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