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SJT: Learning From Adverse Events & System Failures (passthemsra.com) - Free MSRA revision
This episode explores how to turn near-misses and adverse events into system-wide learning using GMC and NHS PSIRF principles. It breaks down national expectations on logging, compassionate engagement, proportional analysis, just culture, and delivering SMART, accountable actions. A high-yield MSRA SJT guide to replacing blame with visibility, candour and system improvement.
0:00 Wrong-site near miss
00:22 Why this moment matters
00:44 Safety first, then systems thinking
01:05 Definition of adverse events
01:38 National learning duties (GMC/NHS)
02:05 Why near misses are gold-mine data
02:40 LFPSC logging explained
03:10 Visibility → prevention
03:40 LEARN framework overview
04:10 L = Log early
04:40 E = Engage with candour
05:10 A = Analyse proportionately (PSIRF)
05:55 Sledgehammer vs scalpel investigations
06:20 Human error vs reckless behaviour
06:48 Just culture principles
07:20 Engaging patients and families
08:00 Silence as an ethical red flag
08:45 R = React with SMART actions
09:20 Specific, measurable fixes
10:00 Common low-scoring traps
10:40 N = Notify and share learning
11:20 Feedback loops and audit
11:50 Four-pillar recap
12:20 Final reflective challenge
• Near misses reveal the same vulnerabilities as harmful events
• LFPSC logging is mandatory for visibility and national learning
• PSIRF = proportionate, system-focused investigation
• Just culture distinguishes human error from reckless acts
• Candour applies even when no harm occurred
• SMART actions outperform blame or retraining
• Learning must be shared, not isolated
• Feedback and metrics close the loop and ensure real change
LEARN mnemonic:
• L – Log early
• E – Engage compassionately
• A – Analyse proportionately (PSIRF)
• R – React with SMART actions
• N – Notify/share and track impact
Links:
• passthemsra.com – Complete MSRA revision, notes, mocks, flashcards
• freemsra.com – Free podcasts, threads and rapid-learning guides
• msra.io – Smart MSRA Qbank with analytics
#MSRA #SJT #MedicalRevision #UKDoctors #PatientSafety #PSIRF #JustCulture #LFPSC #AdverseEvents #SystemsThinking #passthemsra #freemsra #msraio
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By Pass the MSRAThis episode explores how to turn near-misses and adverse events into system-wide learning using GMC and NHS PSIRF principles. It breaks down national expectations on logging, compassionate engagement, proportional analysis, just culture, and delivering SMART, accountable actions. A high-yield MSRA SJT guide to replacing blame with visibility, candour and system improvement.
0:00 Wrong-site near miss
00:22 Why this moment matters
00:44 Safety first, then systems thinking
01:05 Definition of adverse events
01:38 National learning duties (GMC/NHS)
02:05 Why near misses are gold-mine data
02:40 LFPSC logging explained
03:10 Visibility → prevention
03:40 LEARN framework overview
04:10 L = Log early
04:40 E = Engage with candour
05:10 A = Analyse proportionately (PSIRF)
05:55 Sledgehammer vs scalpel investigations
06:20 Human error vs reckless behaviour
06:48 Just culture principles
07:20 Engaging patients and families
08:00 Silence as an ethical red flag
08:45 R = React with SMART actions
09:20 Specific, measurable fixes
10:00 Common low-scoring traps
10:40 N = Notify and share learning
11:20 Feedback loops and audit
11:50 Four-pillar recap
12:20 Final reflective challenge
• Near misses reveal the same vulnerabilities as harmful events
• LFPSC logging is mandatory for visibility and national learning
• PSIRF = proportionate, system-focused investigation
• Just culture distinguishes human error from reckless acts
• Candour applies even when no harm occurred
• SMART actions outperform blame or retraining
• Learning must be shared, not isolated
• Feedback and metrics close the loop and ensure real change
LEARN mnemonic:
• L – Log early
• E – Engage compassionately
• A – Analyse proportionately (PSIRF)
• R – React with SMART actions
• N – Notify/share and track impact
Links:
• passthemsra.com – Complete MSRA revision, notes, mocks, flashcards
• freemsra.com – Free podcasts, threads and rapid-learning guides
• msra.io – Smart MSRA Qbank with analytics
#MSRA #SJT #MedicalRevision #UKDoctors #PatientSafety #PSIRF #JustCulture #LFPSC #AdverseEvents #SystemsThinking #passthemsra #freemsra #msraio