Learning from Adverse Events

SJT Textbook: Learning from Adverse Events

Learning from Adverse Events MSRA

This guide covers the systemic side of Dealing with Errors. In the Professional Dilemmas paper, you must demonstrate an understanding that “human error” is usually a symptom of a deeper system flaw, which is why the NHS has moved to the PSIRF framework.

🎥 Video Lesson (YouTube)

🎧 Podcast Lesson (Spotify / Apple / Amazon)

🎯 THE CORE PRINCIPLE

Learning from adverse events means turning incidents and near misses into safer care through a structured sequence: record, engage, analyse, act, and share. The focus is on understanding what happened, why it happened in context, and how to prevent recurrence at both individual and system levels.

Modern NHS practice uses national systems such as LFPSE to log patient safety events and PSIRF to guide a proportionate response. Rather than investigating everything in the same way, PSIRF promotes the right level of review based on risk, impact and learning potential. A “just and learning culture” underpins this, supporting staff to speak up and engage without fear of unfair blame.

In MSRA SJT questions, higher-scoring options show you logging events (including near misses), engaging patients, families and staff with candour and compassion, selecting an appropriate PSIRF-style review, identifying contributory system factors, and implementing SMART actions with clear ownership and follow-up. Low-scoring options ignore events, focus on punishment, or fail to act on findings.

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Log adverse events and near misses promptly using LFPSE or local safety systems so they are visible for learning.
2. Engage patients, families and staff compassionately, including duty of candour where required, and agree how they wish to be kept informed.
3. Choose a proportionate PSIRF-aligned response (e.g. rapid review, safety huddle, or more detailed investigation) based on risk and learning value.
4. Analyse events with a systems and human-factors lens, looking at workload, communication, processes and environment, not just individual behaviour.
5. Generate SMART actions with clear owners, deadlines and measures that address root and contributory factors.
6. Integrate actions into local governance (e.g. practice meetings, clinical governance, theatre debriefs) to ensure they are tracked.
7. Share key learning from the event with relevant teams and services so improvements spread beyond the original setting.
8. Monitor impact using data or observable behaviours, and revisit if risks persist or actions are not effective.
9. Promote a just culture by using fair, non-punitive language and challenging “name-and-shame” responses.
10. Link personal reflection and portfolio learning to system actions, demonstrating both individual and organisational improvement.

Good options show proportionate, systems-focused learning: events are logged, those affected are involved, contributory factors are analysed, and practical actions are implemented and shared.

💬 MODEL PHRASES (Use These in SJT Logic)

* “Let us agree with the patient and family how they would like to be updated on what we have learned and what will change.”
* “We have identified contributory factors and converted them into SMART actions with named owners and review dates.”
* “Learning from this event will be shared at the next safety huddle and governance meeting so other teams can benefit.”
* “We will monitor key measures over the next month and revisit if the risk has not reduced.”

Log • Engage • Analyse (proportionately) • React (SMART actions) • Notify/feedback

📋 QUICK FAQ

Do we investigate every event in the same way?
No. PSIRF emphasises a proportionate response. Some events are best explored via local huddles or mini-reviews, while others require more formal investigation. The aim is the right level of scrutiny for the risk and learning value.

Should near misses be logged as well as harm events?
Yes. Near misses often expose the same weaknesses as harm events, but without the consequence. Logging and analysing them is a powerful way to prevent future harm.

How should patients and families be involved?
Agree how they wish to be contacted, provide honest explanations, apologise where appropriate, and explain what is being done to reduce the chance of recurrence. This links closely with duty of candour.

What makes an action plan effective rather than cosmetic?
Actions should be SMART: specific, measurable, achievable, relevant and time-bound, with named owners and agreed follow-up. They must address underlying contributory factors, not just remind staff to “be more careful”.

What if the local culture feels blame-focused or dismissive of events?
Raise concerns with a supervisor or safety lead, reference just-culture and PSIRF principles, and model fair, learning-focused language. If necessary, escalate via formal channels or guardians for safe working.

How do I show my own learning in this process?
Link event analysis to your personal reflection and development plan, describing what you will do differently and how you will contribute to team or system improvements.

📚 GMC ANCHOR POINTS

• Promote and protect patient safety, contributing to a culture that learns from mistakes (GMC Good medical practice 2024).
• Be open and honest with patients when things go wrong, and explain what will change (GMC candour guidance).
• Take part in quality improvement and clinical governance activities (GMC Good medical practice 2024, improvement and governance duties).
• Treat colleagues fairly and support a working environment where people can raise concerns without unfair blame (GMC Good medical practice 2024, teamwork and leadership).
• Keep accurate, timely records of decisions, actions and follow-up plans related to safety events (GMC Recording information).

💡 MINI PRACTICE SCENARIO

A wrong-site nerve block is averted during the WHO time-out; the error is caught before injection. The patient has not yet been told. The theatre team feel shaken, but someone suggests that “as no harm happened, we should just move on”.

Best action: Log the near miss on LFPSE, agree a proportionate PSIRF-style review focusing on contributory system factors, inform the patient with candour about what happened and what will change, and implement SMART actions with clearly assigned owners and timelines.
Why: This approach recognises near misses as learning opportunities, meets candour expectations, focuses on systems rather than blame, and ensures actions are implemented and reviewed.

🎯 KEY TAKEAWAYS

✓ Near misses as well as harm events should be logged and learned from.
✓ PSIRF promotes proportionate, systems-focused responses rather than one-size-fits-all investigations.
✓ Patients, families and staff should be engaged compassionately and kept informed.
✓ SMART actions with owners, timelines and measures turn learning into safer practice.
✓ Feedback and monitoring are essential to close the loop and check impact.
✓ Just culture avoids blame and supports staff to speak up and participate in learning.

🔗 RELATED TOPICS

* → Duty of Candour and Disclosing Mistakes
* → Reflective Practice After an Error
* → Supporting Colleagues After Incidents
* → Responding to Patient Complaints
* → Patient Safety Incident Reporting (LFPSE and PSIRF)

📖 FULL PRACTICE QUESTIONS

Example SJT — Best of 3 (8 options; choose three)

You are an ST3 in anaesthetics. In theatre, a wrong-site nerve block is almost performed but is stopped during the WHO time-out when a scrub nurse queries the consent form. No injection is given and the correct site is confirmed and used. The list is busy, but everyone is unsettled. You are considering what should happen next.

Options:
A. Carry on with the list and take no further action because no harm occurred.
B. Log the near miss on LFPSE and document brief factual details in the clinical record.
C. Send a trust-wide email naming the anaesthetist who prepared the block as a warning to others.
D. Propose a proportionate PSIRF-style review focusing on checks, communication and list pressures, rather than on individuals.
E. Inform the patient after the operation about what nearly happened, apologise, and explain what will be done to reduce the chance of recurrence.
F. Decide to “deal with it within the theatre team” and keep all findings off formal systems.
G. Introduce a SMART action plan including a revised local safety checklist, team brief emphasis on site-marking, and auditing compliance.
H. Advise colleagues not to log near misses in future because “it only causes trouble”.

Example SJT — Rank 5 (best → worst)

You are a GP trainee in a large practice. A delayed follow-up of abnormal blood tests led to a patient being admitted with decompensated heart failure. The patient has been treated and is improving. An initial incident note has been made in LFPSE. At the next practice meeting, several possible responses are suggested.

Options:
A. Review the pathway using a PSIRF-style proportionate practice review, map contributory factors (e.g. result handling, staff workload, IT prompts), create SMART actions with named owners and timelines, and plan to share learning across the PCN.
B. Agree that everyone should “just be more careful” and move on without specific actions or follow-up.
C. Ask the practice manager to send an email criticising the duty doctor who saw the original result.
D. Decide to carry out full root-cause analyses on every delayed result for the last five years, even if minor, before making any changes.
E. Keep the LFPSE report hidden and tell staff not to mention the case outside the meeting.