This review article presents the development of a revised and expanded edition of the widely used London Protocol, originally introduced in 2004 as a structured approach for investigating clinical incidents within healthcare systems. The authors, a multidisciplinary and international team led by Charles Vincent, provide a compelling rationale for updating the protocol in response to significant evolutions in healthcare delivery, safety science, and the expectations surrounding incident analysis.
The article opens by contextualizing the critical role of incident analysis in safety-critical industries and acknowledges the foundational influence of the London Protocol in shaping systems-based approaches to patient safety. Despite its widespread adoption and translation into multiple languages, the authors argue that the original protocol has become outdated due to changes in the healthcare landscape, such as increased complexity of patient care, the integration of primary and community services, and the growing emphasis on involving patients and families.
A significant contribution of the new edition is its integration of insights from a comprehensive narrative review of incident investigation methods conducted between 1990 and 2024. The findings suggest that while many approaches (e.g., Root Cause Analysis, HFACS, STAMP, AcciMap) are in use, only a few offer the systemic, multifactorial insight that complex incidents require. The revised London Protocol addresses these gaps with several major updates:
- Stronger guidance on engaging patients and families early in the investigation process.
- Emphasis on psychological and organizational support post-incident.
- Inclusion of thematic and longitudinal analyses to capture systemic issues.
- Recommendations for direct observation of work settings to better understand contextual factors.
- Detailed instruction on formulating actionable and prioritized recommendations.
- Enhanced structure for writing safety reports that facilitate organizational learning.
The article also proposes research directions to improve the methodological robustness of incident investigations, including standardization of terminology, rigorous assessment of investigation quality, and strategies for prioritizing and implementing recommendations.
Finally, the authors stress the importance of integrating the revised protocol within institutional and national safety systems. They note that complementary frameworks, such as England’s Patient Safety Incident Response Framework (PSIRF), benefit from practical tools like the London Protocol, which provide the procedural clarity needed to operationalize system-level learning.
This updated protocol represents a matured, evidence-informed guide that adapts to contemporary challenges in healthcare safety. It reinforces the necessity of a proactive, reflective, and inclusive approach to incident investigation—an essential component of resilient and learning-oriented healthcare systems.
Reference:
Vincent, C., Irving, D., Bellandi, T., Higham, H., Michel, P., Staines, A., … & Zambon, L. (2025). Systems analysis of clinical incidents: development of a new edition of the London Protocol. BMJ Quality & Safety, 34(6), 413–420. https://doi.org/10.1136/bmjqs-2024-017987
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