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module menu icon The analytical process: the London Protocol

There are seven stages of the London Protocol’s investigative process. These are: 

  1. Identifying and deciding to investigate an incident 
    The reason to investigate something in the first place is either because it has a serious outcome, or because there appears to be an important lesson to be learned from it, regardless of the outcome. Note that the second point suggests that it could be a near miss rather an incident that needs investigating. For brevity, these will all be referred to as “incidents” here.
  2. Selecting people for the investigation team 
    This depends on the seriousness of the incident. If the incident is serious, then a number of team roles may be needed. For a less serious incident, possibly just the pharmacist or pharmacy manager and whoever else has relevant knowledge or expertise will need to be involved.
  3. Organising and gathering data 
    In settings such as primary care, data collection involves starting with the incident itself and then working backwards in time until enough information has been gathered to understand how the incident occurred.
    If interviewing anyone is needed, then the interview should be carried out in a timely and supportive manner, keeping the focus on information gathering. 
  4. Establishing the chronology of the incident 
    Once enough information about the incident has been gathered, then the next step is to work out what happened and when. It is up to the individual about how to do this, but two ideas for representing the information are using a simple timeline or a time-person grid.
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