{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,11]],"date-time":"2026-10-11T23:36:02Z","timestamp":1791761762155,"version":"4.3.4"},"reference-count":67,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2025,2,22]],"date-time":"2025-02-22T00:00:00Z","timestamp":1740182400000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Qual Saf"],"accepted":{"date-parts":[[2025,1,22]]},"published-print":{"date-parts":[[2025,6]]},"abstract":"<jats:p>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, we describe the development of a new edition of the London Protocol. We 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. We describe a systematic process of development of the new edition drawing on the findings of a narrative review of incident analysis methods. The principal changes in the new edition are as follows: increased emphasis and guidance on the engagement of patients and families as partners in the investigation; giving more attention to the support of patients, families and staff in the aftermath of an incident; emphasising the value of a small number of in-depth analyses combined with thematic reviews of wider problems; including proposals and guidance for the examination of much longer time periods; emphasising the need to highlight good care as well as problems; adding guidance on direct observation of the work environment; providing a more structured and wide-ranging approach to recommendations and including more guidance on how to write safety incident reports. Finally, we offer some proposals to place research on incident analysis on a firmer foundation and make suggestions for the practice and implementation of incident investigation within safety management systems.<\/jats:p>","DOI":"10.1136\/bmjqs-2024-017987","type":"journal-article","created":{"date-parts":[[2025,2,22]],"date-time":"2025-02-22T20:20:25Z","timestamp":1740255625000},"page":"413-420","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":23,"title":["Systems analysis of clinical incidents: development of a new edition of the London Protocol"],"prefix":"10.1136","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0270-0222","authenticated-orcid":false,"given":"Charles","family":"Vincent","sequence":"first","affiliation":[{"name":"Experimental Psychology, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6005-8648","authenticated-orcid":false,"given":"Dulcie","family":"Irving","sequence":"additional","affiliation":[{"name":"Experimental Psychology, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tommaso","family":"Bellandi","sequence":"additional","affiliation":[{"name":"Patient Safety, Tuscany Northwest Trust, Regional Health Service of Tuscany, Lucca, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5796-0377","authenticated-orcid":false,"given":"Helen","family":"Higham","sequence":"additional","affiliation":[{"name":"Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philippe","family":"Michel","sequence":"additional","affiliation":[{"name":"Quality Management, Centre Hospitalier Universitaire de Lyon, Lyon, Auvergne-Rh\u00f4ne-Alpes, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony","family":"Staines","sequence":"additional","affiliation":[{"name":"Patient Safety Programme, F\u00e9d\u00e9ration des h\u00f4pitaux vaudois, Clarmont, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sally","family":"Adams","sequence":"additional","affiliation":[{"name":"East London NHS Foundation Trust, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeff","family":"Brown","sequence":"additional","affiliation":[{"name":"Patients for Patients Safety, Georgetown, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7865-343X","authenticated-orcid":false,"given":"Peter Damian","family":"Hibbert","sequence":"additional","affiliation":[{"name":"Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carole","family":"Hemmelgarn","sequence":"additional","affiliation":[{"name":"Patients for Patients Safety, Georgetown, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6938-1265","authenticated-orcid":false,"given":"Lallu","family":"Joseph","sequence":"additional","affiliation":[{"name":"Christian Medical College Vellore, Vellore, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karina","family":"Pires","sequence":"additional","affiliation":[{"name":"Brazilian Institute for Patient Safety (IBSP), S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"Sheridan","sequence":"additional","affiliation":[{"name":"Patients for Patient Safety US, Georgetown, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosa","family":"Sunol","sequence":"additional","affiliation":[{"name":"Avedis Donabedian Research Institute, Universitat Aut\u00f2noma de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shin","family":"Ushiro","sequence":"additional","affiliation":[{"name":"Division of Patient Safety, Kyushu University Hospital, Fukuoka, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6189-7120","authenticated-orcid":false,"given":"Albert W","family":"Wu","sequence":"additional","affiliation":[{"name":"Center for Health Services and Outcomes Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2303-4702","authenticated-orcid":false,"given":"Lucas","family":"Zambon","sequence":"additional","affiliation":[{"name":"Brazilian Institute for Patient Safety (IBSP), S\u00e3o Paulo, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,2,22]]},"reference":[{"key":"2025090409290076000_34.6.413.1","unstructured":"World Health Organisation . Patient safety incident reporting and learning systems: technical report and guidance. 2020. Available: https:\/\/iris.who.int\/bitstream\/handle\/10665\/334323\/9789240010338-eng.pdf?sequence=1"},{"key":"2025090409290076000_34.6.413.2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2016-005511"},{"key":"2025090409290076000_34.6.413.3","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-004732"},{"key":"2025090409290076000_34.6.413.4","first-page":"97","article-title":"Your RCA (root-cause analysis): how do you select events for analysis?","volume":"24","author":"Spath","year":"1999","journal-title":"Hosp Peer Rev"},{"key":"2025090409290076000_34.6.413.5","unstructured":"Veterans Hospital Administration . Guide to performing a root cause analysis. VHA National Center for Patient Safety; 2021. Available: https:\/\/www.patientsafety.va.gov\/docs\/RCA-Guidebook_02052021.pdf"},{"key":"2025090409290076000_34.6.413.6","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.320.7237.777"},{"key":"2025090409290076000_34.6.413.7","doi-asserted-by":"publisher","DOI":"10.1258\/1356262042368255"},{"key":"2025090409290076000_34.6.413.8","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2004.010454"},{"key":"2025090409290076000_34.6.413.9","doi-asserted-by":"crossref","first-page":"16","DOI":"10.12927\/hcq.2006.18449","article-title":"Five Years of Learning from Analysis of Clinical Occurrences in Pediatric Care Using the London Protocol","volume":"9","author":"Cronin","year":"2006","journal-title":"Healthc Q"},{"key":"2025090409290076000_34.6.413.10","doi-asserted-by":"publisher","DOI":"10.1192\/bji.2020.43"},{"key":"2025090409290076000_34.6.413.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.transproceed.2010.05.034"},{"key":"2025090409290076000_34.6.413.12","doi-asserted-by":"publisher","DOI":"10.1080\/13218719.2022.2142977"},{"key":"2025090409290076000_34.6.413.13","article-title":"Patient Safety in Complementary Medicine through the Application of Clinical Risk Management in the Public Health System","volume":"4","author":"Rossi","year":"2017","journal-title":"Medicines (Basel)"},{"key":"2025090409290076000_34.6.413.14","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.4.2.80"},{"key":"2025090409290076000_34.6.413.15","unstructured":"Reason J . Human error. Cambridge (GB): Cambridge university press, 1990."},{"key":"2025090409290076000_34.6.413.16","doi-asserted-by":"publisher","DOI":"10.1098\/rstb.1990.0088"},{"key":"2025090409290076000_34.6.413.17","doi-asserted-by":"publisher","DOI":"10.1016\/S0925-7535(97)00052-0"},{"key":"2025090409290076000_34.6.413.18","doi-asserted-by":"publisher","DOI":"10.1016\/S0925-7535(03)00047-X"},{"key":"2025090409290076000_34.6.413.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2011.12.006"},{"key":"2025090409290076000_34.6.413.20","doi-asserted-by":"crossref","unstructured":"Vincent C , Amalberti R . Safer healthcare: strategies for the real world. Springer Nature, 2016.","DOI":"10.1007\/978-3-319-25559-0"},{"key":"2025090409290076000_34.6.413.21","doi-asserted-by":"publisher","DOI":"10.1186\/s12916-018-1057-z"},{"key":"2025090409290076000_34.6.413.22","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-017-0695-4"},{"key":"2025090409290076000_34.6.413.23","doi-asserted-by":"publisher","DOI":"10.1111\/hex.13478"},{"key":"2025090409290076000_34.6.413.24","unstructured":"NHS England . Engaging and involving patients, families and staff following a patient safety incident. NHS England, London, UK; 2022. Available: https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2022\/08\/B1465-2.-Engaging-and-involving...-v1-FINAL.pdf"},{"key":"2025090409290076000_34.6.413.25","doi-asserted-by":"publisher","DOI":"10.1080\/1364557032000119616"},{"key":"2025090409290076000_34.6.413.26","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-5-69"},{"key":"2025090409290076000_34.6.413.27","first-page":"203","article-title":"Investigations by acute-hospital staff: AcciMaps or HFACS","volume":"4","author":"Woodier","year":"2022","journal-title":"Contemp Ergon Hum Factors"},{"key":"2025090409290076000_34.6.413.28","doi-asserted-by":"crossref","first-page":"34","DOI":"10.33940\/culture\/2022.6.3","article-title":"Implementation of Improvements Based on the Analysis of Severe Adverse Events in Pediatric Patients","volume":"4","author":"Bigio","year":"2022","journal-title":"PatientSaf"},{"key":"2025090409290076000_34.6.413.29","doi-asserted-by":"publisher","DOI":"10.1177\/2516043521990261"},{"key":"2025090409290076000_34.6.413.30","doi-asserted-by":"publisher","DOI":"10.1016\/j.apergo.2018.04.012"},{"key":"2025090409290076000_34.6.413.31","doi-asserted-by":"publisher","DOI":"10.1016\/j.bpa.2020.04.013"},{"key":"2025090409290076000_34.6.413.32","doi-asserted-by":"publisher","DOI":"10.1080\/00140139.2015.1057542"},{"key":"2025090409290076000_34.6.413.33","doi-asserted-by":"crossref","DOI":"10.37689\/acta-ape\/2021AO001165","article-title":"Patient safety centers: profile of human resources in the Brazilian scenario","volume":"34","author":"Mello","year":"2021","journal-title":"Acta Paul Enferm"},{"key":"2025090409290076000_34.6.413.34","doi-asserted-by":"crossref","first-page":"1099","DOI":"10.1590\/S0080-623420130000500013","article-title":"Improving patient safety: how and why incidences occur in nursing care","volume":"47","author":"Toffoletto","year":"2013","journal-title":"Rev Esc Enferm USP"},{"key":"2025090409290076000_34.6.413.35","doi-asserted-by":"publisher","DOI":"10.1177\/0018720818771904"},{"key":"2025090409290076000_34.6.413.36","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2016-006229"},{"key":"2025090409290076000_34.6.413.37","unstructured":"Nemeth CP . Health care forensics. In: Handbook of human factors in litigation. CRC Press, 2024: 896\u2013918."},{"key":"2025090409290076000_34.6.413.38","doi-asserted-by":"publisher","DOI":"10.1001\/jama.299.6.685"},{"key":"2025090409290076000_34.6.413.39","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2016-005991"},{"key":"2025090409290076000_34.6.413.40","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzx181"},{"key":"2025090409290076000_34.6.413.41","doi-asserted-by":"publisher","DOI":"10.1016\/j.ssci.2009.01.004"},{"key":"2025090409290076000_34.6.413.42","unstructured":"National Institute of Health & Care Research . Learn together. NIHR; 2024. Available: https:\/\/learn-together.org.uk\/"},{"key":"2025090409290076000_34.6.413.43","doi-asserted-by":"publisher","DOI":"10.1136\/archdischild-2020-320630"},{"key":"2025090409290076000_34.6.413.44","doi-asserted-by":"crossref","DOI":"10.1177\/21501319221102041","article-title":"Convergence of Service Providers and Managers\u2019 Perspectives on Strengths, Gaps, and Priorities for Rural Health System Redesign: A Whole-Systems Qualitative Study in Washington County, Maine","volume":"13","author":"West","year":"2022","journal-title":"J Prim Care Community Health"},{"key":"2025090409290076000_34.6.413.45","unstructured":"Leveson NG . Designing a safety management system. In: Leveson NG , ed. An introduction to system safety engineering. Cambridge: MIT Press, 2023: 429\u201370."},{"key":"2025090409290076000_34.6.413.46","doi-asserted-by":"crossref","DOI":"10.3389\/frhs.2024.1473296","article-title":"Humanising processes after harm part 2: compounded harm experienced by patients and their families after safety incidents","volume":"4","author":"Ramsey","year":"2024","journal-title":"Front Health Serv"},{"key":"2025090409290076000_34.6.413.47","doi-asserted-by":"crossref","DOI":"10.1136\/bmjoq-2022-002020","article-title":"Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report","volume":"12","author":"Machen","year":"2023","journal-title":"BMJ Open Qual"},{"key":"2025090409290076000_34.6.413.48","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-085854","article-title":"Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study","volume":"14","author":"Hibbert","year":"2024","journal-title":"BMJ Open"},{"key":"2025090409290076000_34.6.413.49","first-page":"434","article-title":"Using aggregate root cause analysis to improve patient safety","volume":"29","author":"Neily","year":"2003","journal-title":"Jt Comm J Qual Saf"},{"key":"2025090409290076000_34.6.413.50","unstructured":"Murrin S . Patient safety organizations: hospital participation, value, and challenges. Report no. OEI-01-17-00420. US Department of Health and Human Services Office of Inspector General; 2019. Available: https:\/\/oig.hhs.gov\/documents\/evaluation\/2607\/OEI-01-17-00420-Complete%20Report.pdf"},{"key":"2025090409290076000_34.6.413.51","doi-asserted-by":"publisher","DOI":"10.1016\/j.jemermed.2019.11.015"},{"key":"2025090409290076000_34.6.413.52","doi-asserted-by":"publisher","DOI":"10.1186\/s12873-019-0289-3"},{"key":"2025090409290076000_34.6.413.53","unstructured":"NHS England . Patient safety incident response framework. London, UK NHS England; 2022."},{"key":"2025090409290076000_34.6.413.54","unstructured":"Berwick DM . Berwick review into patient safety. United Kingdom: Department of Health and Social Care; 2013. Available: https:\/\/www.gov.uk\/government\/publications\/berwick-review-into-patient-safety"},{"key":"2025090409290076000_34.6.413.55","unstructured":"Clinical Excellence Commission . Serious adverse event review: systems analysis of clinical incidents - London Protocol (2nd edition) toolkit. New South Wales Government; 2020. Available: https:\/\/www.cec.health.nsw.gov.au\/__data\/assets\/pdf_file\/0011\/606746\/London-Protocol-Toolkit.pdf"},{"key":"2025090409290076000_34.6.413.56","unstructured":"Haute Autorit\u00e9 de Sant\u00e9 . ALARM grid. 2022. Available: https:\/\/www.has-sante.fr\/jcms\/c_1215806\/fr\/grille-alarm"},{"key":"2025090409290076000_34.6.413.57","doi-asserted-by":"crossref","unstructured":"Bellandi T , Romani-Vidal A , Sousa P , et al . Adverse event investigation and risk assessment. In: Textbook of patient safety and clinical risk management. 2021: 129.","DOI":"10.1007\/978-3-030-59403-9_11"},{"key":"2025090409290076000_34.6.413.58","unstructured":"Ministry of Health for Spain . Recommendations for the analysis of patient safety incidents with harm (adverse events). Ministry of Health for Spain; 2021. Available: https:\/\/seguridaddelpaciente.sanidad.gob.es\/informacion\/publicaciones\/2021\/docs\/Recomendaciones_para_el_analisis_de_los_incidentes_de_seguridad_del_paciente_con_dano._Accesible.pdf"},{"key":"2025090409290076000_34.6.413.59","unstructured":"Swiss Patient Safety Foundation . Cours ERA 2025. The Swiss Patient Safety Foundation; 2025. Available: https:\/\/patientensicherheit.ch\/wp\/wp-content\/uploads\/2024\/11\/Descriptif_ERA_2025.pdf"},{"key":"2025090409290076000_34.6.413.60","unstructured":"World Health Organization . Patient safety curriculum guide: multi-professional edition. World Health Organization, 2011."},{"key":"2025090409290076000_34.6.413.61","unstructured":"Health Services Investigation Body . Who we are. 2023. Available: https:\/\/www.hssib.org.uk\/about-us\/who-we-are\/"},{"key":"2025090409290076000_34.6.413.62","unstructured":"Haute Autorit\u00e9 de Sant\u00e9 . Patient safety. 2022. Available: https:\/\/has-sante.fr\/jcms\/c_2042652\/en\/patient-safety"},{"key":"2025090409290076000_34.6.413.63","unstructured":"Swiss Patient Safety Foundation . Quick alerts. 2024. Available: https:\/\/patientensicherheit.ch\/fr\/cirrnet-3\/quick-alerts-fr\/"},{"key":"2025090409290076000_34.6.413.64","doi-asserted-by":"crossref","DOI":"10.3389\/fpubh.2023.1087268","article-title":"Naming the 'baby' or the 'beast'? The importance of concepts and labels in healthcare safety investigation","volume":"11","author":"Wiig","year":"2023","journal-title":"Front Public Health"},{"key":"2025090409290076000_34.6.413.65","unstructured":"Pennsylvania Patient Safety Authority . Safety alerts. 2023. Available: https:\/\/patientsafety.pa.gov\/NewsAndInformation"},{"key":"2025090409290076000_34.6.413.66","unstructured":"Japan Council for Quality Healthcare . Outline. 2022. Available: https:\/\/www.med-safe.jp\/contents\/english\/index.html"},{"key":"2025090409290076000_34.6.413.67","doi-asserted-by":"publisher","DOI":"10.4415\/ANN_19_04_10"}],"container-title":["BMJ Quality &amp; Safety"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjqs-2024-017987","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,4]],"date-time":"2025-09-04T16:29:14Z","timestamp":1757003354000},"score":1,"resource":{"primary":{"URL":"https:\/\/qualitysafety.bmj.com\/lookup\/doi\/10.1136\/bmjqs-2024-017987"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,22]]},"references-count":67,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,5,19]]},"published-print":{"date-parts":[[2025,6]]}},"alternative-id":["10.1136\/bmjqs-2024-017987"],"URL":"https:\/\/doi.org\/10.1136\/bmjqs-2024-017987","relation":{},"ISSN":["2044-5415","2044-5423"],"issn-type":[{"value":"2044-5415","type":"print"},{"value":"2044-5423","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,22]]}}}