How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol.

Analyses of clinical incidents should focus less on individuals and more on organisational factors. Use of a formal protocol ensures a systematic, comprehensive, and efficient investigation. The protocol reduces the chance of simplistic explanations and routine assignment of blame. Experience with the protocol suggests that training is needed for it to be used effectively. Analysis of incidents is a powerful method of learning about healthcare organisations. Organisational analyses lead directly to strategies for enhancing patient safety