London Protocol
RCA Framework & Process

Every day, thousands of patients are treated safely and compassionately by highly skilled healthcare professionals. On occasion, things go wrong that result in poor outcomes for patients, carers and their families. When a serious incident occurs, action is taken to reduce or prevent or reduce the likelihood of future harm. Serious clinical incidents undergo a serious adverse event review.

The London Protocol of Root cause analysis (RCA) is the structured method used to review an incident in order to identify the healthcare systems issues that contributed to patient harm. By understanding the factors that caused or contributed to an incident, teams can improve patient safety and take action to prevent future harm

The London Protocol Framework

The London Protocol takes a systems approach to incident review and was developed for the healthcare context by patient safety expert Charles Vincent.

The London Protocol is a two-stage process. It identifies problems that may have occurred during the care delivery process, and then any contributory factors present at the time of the incident.

Care Delivery Problems

Care delivery problems (CDPs) are problems that arise in the process of care, usually actions or omissions by staff. The two essential features are:

  • Care deviated beyond safe limits of practice

  • The deviation had at least a potential direct or indirect effect on the adverse outcome for the patient, member of staff or general public.

Contributory Factors

Many factors may contribute to a single CDP. The factors are listed below with examples. The diagram above provides a framework for contributory factor types that should be considered.

  • Patient factors e.g. the patient was very distressed or unable to understand instructions.

  • Task and technology factors, e.g. poor equipment design or the absence of protocols

  • Individual factors e.g. lack of knowledge or experience of particular staff

  • Team factors, e.g. poor communication between staff

  • Work environment factors, e.g. an unusually high workload or inadequate staffing.