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 miss00:22 Why this moment matters00:44 Safety first, then systems thinking01:05 Definition of adverse events01:38 National learning duties (GMC/NHS)02:05 Why near misses are gold-mine data02:40 LFPSC logging explained03:10 Visibility → prevention03:40 LEARN framework overview04:10 L = Log early04:40 E = Engage with candour05:10 A = Analyse proportionately (PSIRF)05:55 Sledgehammer vs scalpel investigations06:20 Human error vs reckless behaviour06:48 Just culture principles07:20 Engaging patients and families08:00 Silence as an ethical red flag08:45 R = React with SMART actions09:20 Specific, measurable fixes10:00 Common low-scoring traps10:40 N = Notify and share learning11:20 Feedback loops and audit11:50 Four-pillar recap12:20 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 changeLEARN mnemonic:• L – Log early• E – Engage compassionately• A – Analyse proportionately (PSIRF)• R – React with SMART actions• N – Notify/share and track impactLinks:• 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