Systems Analysis of Clinical Incidents: The London Protocol

Clinical Safety Research Unit, Imperial College London
London, United Kingdom


The purpose of the London Protocol is to ensure a comprehensive and thoughtful investigation and analysis of a clinical 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 in this protocol does not supplant clinical expertise or deny the importance of the reflections of individual clinicians on an incident. Rather the aim of this approach is to utilize clinical experience and expertise to the fullest extent, and to assist the reflective investigation process.



The London Protocol is the revised and updated version of the original "Protocol for the Investigation and Analysis of Clinical Incidents." The initial 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 revised approach has now been refined and developed in the light of experience and research into incident investigation both within and outside health care. The principal authors of the London Protocol include Sally Taylor-Adams, PhD, of the UK's National Patient Safety Agency, and Charles Vincent, PhD, of the Clinical Safety Research Unit at Imperial College London.

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