Wednesday 12 August 2025 | 09:30-12:30

Format: Workshop

This workshop teaches participants to bring the elucidation of human factors to the fore when investigating clinical incidents, with the aim that impactful and sustainable improvements can be made to systems and human performance.

Participants will learn experientially by conducting interviews with interactive role players, portraying the first, second and third victims of incidents crafted from actual occurrences in our campus.

Those who conduct incident investigations or are in positions of accountability to make decisions on post-incident recommendations should attend this workshop.

Through the workshop, participants will better appreciate how the scientific rigour of investigation is applied in tandem with the art of understanding human behaviour and frailties of healthcare providers. They will explore the various types of human errors to enhance their ability to conduct nuanced investigations.

With this enhanced appreciation, we envisage that participants will be better able to identify latent error, implement interventions that address root cause of human and system error, and create safer and more reliable environments for patients and healthcare providers.

After this session, participants will be able to:

• Apply human factors concepts on how to conduct system-based incident investigations that transcend beyond individual blame, incorporating models of human information processing and taxonomies of unsafe acts.


• Practice crucial skills such as conducting RCA interviews and speaking with staff in a fair, learning-focused way after adverse events, utilising human factors principles to enhance communication and understanding.


• Develop effective recommendations using a hierarchy of interventions model to create sustainable changes that address root causes, considering various types of errors including perceptual, decision, and execution errors.

Tan Hai Yang Ng Teng Fong General Hospital (NTFGH); Singapore

Chen Yongsheng Ng Teng Fong General Hospital (NTFGH); Singapore

Rexford Del Rosario Ng Teng Fong General Hospital (NTFGH); Singapore

Gerald Chua Ng Teng Fong General Hospital (NTFGH); Singapore

Syahid Hassan Changi General Hospital (CGH); Singapore

Tan Yuen Ming Ng Teng Fong General Hospital (NTFGH); Singapore