Before you begin, have you completed the first two modules in this series about COPD?
Part one: The importance of a safety culture

The original CPPE programme was developed in collaboration with the National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (GM PSTRC). The NIHR GM PSTRC is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust.

Disclaimer: This learning programme is intended to aid the assessment of different aspects of patient safety with a view to making improvements. Using it will not, on its own, ensure you are compliant with health and safety legislation. Organisations should evaluate their own level of compliance with the law and seek competent advice if appropriate.

One of the methods for investigating patient safety incidents is known as the London Protocol. This is a systematic process intended to help identify lessons from an incident that can be applied to safety improvement within or across healthcare organisations.

It is similar to root cause analysis as far as execution is concerned, but it has some important philosophical differences regarding the explanation of an incident.

The conceptual model that underlies the London Protocol shows that contributory factors lead to care delivery problems. These problems can give rise to either a near miss, if the result is stopped by the defences or barriers, or an incident if the result is not stopped. This incident can subsequently lead to harm if its effect is not – or cannot be – detected and dealt with.