De Micco Francesco, Di Palma Gianmarco, Tambone Vittoradolfo, Scendoni Roberto
Research Unit of Bioethics and Humanities, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Roma, Italy.
Operative Research Unit of Department of Clinical Affairs, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Roma, Italy.
Healthcare (Basel). 2025 Aug 14;13(16):2003. doi: 10.3390/healthcare13162003.
Over the past two decades, patient safety and clinical risk management have become strategic priorities for healthcare systems worldwide. In this context, the London Protocol has emerged as one of the most influential methodologies for investigating adverse events through a systemic, non-punitive lens. The 2024 edition, curated by Vincent, Adams, Bellandi, and colleagues, represents a significant evolution of the original 2004 framework. It integrates recent advancements in safety science, human factors, and digital health, while placing a stronger emphasis on resilience, proactive learning, and stakeholder engagement. This article critically examines the structure, key principles, and innovations of the London Protocol 2024, highlighting its departure from incident-centered analysis toward a broader understanding of both failures and successes. The protocol encourages fewer but more in-depth investigations, producing actionable and sustainable recommendations rather than generic reports. It also underscores the importance of involving patients and families as active partners in safety processes, recognizing their unique perspectives on communication, care pathways, and system failures. Beyond its strengths-holistic analysis, multidisciplinary collaboration, and cultural openness-the systemic approach presents challenges, including methodological complexity, resource requirements, and cultural resistance in blame-oriented environments. This paper discusses these limitations and explores how leadership, staff engagement, and digital technologies (including artificial intelligence) can help overcome them. Ultimately, the London Protocol 2024 emerges not only as a methodological tool but as a catalyst for cultural transformation, fostering healthcare systems that are safer, more resilient, and committed to continuous learning.
在过去二十年中，患者安全和临床风险管理已成为全球医疗系统的战略重点。在此背景下，《伦敦协议》已成为通过系统的、非惩罚性视角调查不良事件最具影响力的方法之一。由文森特、亚当斯、贝兰迪及其同事精心策划的2024年版，是对2004年原始框架的重大发展。它整合了安全科学、人为因素和数字健康方面的最新进展，同时更加强调恢复力、主动学习和利益相关者参与。本文批判性地审视了《2024年伦敦协议》的结构、关键原则和创新之处，强调其从以事件为中心的分析转向对失败和成功更广泛的理解。该协议鼓励进行更少但更深入的调查，提出可操作且可持续的建议，而非一般性报告。它还强调了让患者和家属作为安全流程中的积极伙伴参与的重要性，认识到他们在沟通、护理路径和系统故障方面的独特观点。除了其优势——全面分析、多学科合作和文化开放性——这种系统方法也带来了挑战，包括方法复杂性、资源需求以及在注重指责的环境中的文化阻力。本文讨论了这些局限性，并探讨了领导力、员工参与和数字技术（包括人工智能）如何有助于克服这些局限性。最终，《2024年伦敦协议》不仅作为一种方法工具出现，而且作为文化变革的催化剂，促进形成更安全、更具恢复力且致力于持续学习的医疗系统。
