Systems analysis of clinical incidents: the London Protocol 2024

Investigating incidents and accidents is crucial for safety management in high-risk industries. While it is just one component of safety management, it is an essential one. Thoughtful incident analysis promotes learning, enhances safety, and fosters a proactive safety culture.

The London Protocol is a method for analysing healthcare incidents, revealing the strengths and weaknesses of the healthcare system. By closely examining a single patient’s journey, valuable insights about the broader system can be gained. Originally published in 2004, it has been widely used around the world.

Find out more about the updated 2024 version of the London Protocol.

In this workshop, you will learn about the updated London Protocol 2024, which has been refined for today’s healthcare landscape. We will cover its history, theoretical background, and our approach to learning from clinical incidents and patient experiences.

We will focus on engaging patients and families and supporting everyone affected by incidents. Additionally, we will discuss the importance of fewer, more thorough investigations to drive broader improvement initiatives.

There will be opportunities for questions and open discussions on any topics raised.

The workshop will be facilitated by Dr. Helen Higham, Director of the OxStar Simulation Centre, and Professor Charles Vincent, Emeritus Professor of Psychology, both at the University of Oxford. Helen and Charles are two of the six authors of the new London Protocol and have extensive experience in patient safety research and practice.

The facilitation style will be informal, encouraging discussion of key issues. We aim to create a safe environment for open dialogue. Please note that while the main presentations will be recorded for resource sharing, the discussion section will not be recorded.

Helen Higham is an Associate Professor at the University of Oxford and a Consultant Anaesthetist at Oxford University Hospitals NHS Foundation Trust. She is the Director of OxSTaR, focusing on simulation and patient safety research. Helen has led NHS safety investigations and developed national training programmes. She is a founding member of the Association for Simulated Practice in Healthcare and contributes to various committees on patient safety.

Charles Vincent is a Professor of Psychology and Emeritus Fellow at the University of Oxford and an Emeritus Professor Clinical Safety Research, Imperial College London, with a focus on patient safety in healthcare. He trained as a Clinical Psychologist and has researched the causes and consequences of patient harm since 1985. He founded the Clinical Risk Unit at University College London and later worked at Imperial College, where he directed the National Institute of Health Research Centre for Patient Safety.