Thursday 14 August 2025 | 10:40-11:10 

Format: Session

Stream: Safety

Part 1: How Human Factors and Ergonomics Can Improve Patient Safety – Case studies from Hong Kong Public Hospitals

Human factors and ergonomics studies humans and their interaction with the surroundings to improve human performance. With the complex work environment in healthcare settings, human factors and ergonomics help improve the design of different aspects of the sociotechnical system by understand the capabilities and limitations to eventually improve patient safety, prevent incidents and enhance patient experience. This presentation shares real case examples in public hospitals of Hong Kong how human factors and ergonomics can be applied to improve system design and monitor effectiveness of improvement actions for sustainability. These examples include modification of mental models, modification of product and environmental design and standardisation of safety practices.

Key session outcomes:

1. Understand what human factors and ergonomics is
2. Understand how human factors and ergonomics can help improve the sociotechnical system and improve patient safety
3. Learn from real cases how human factors and ergonomics can be applied in healthcare settings

Andy Kwok Hospital Authority; Hong Kong

Part 2: Psychological Safety for Sustainable Quality in Healthcare: Empowering Speaking Up, Engendering Civility & Enhancing Trust

In healthcare, sustainable quality hinges on open communication, yet fear of speaking up often undermines trust, leading to errors and missed opportunities for improvement. High-reliability organizations struggle to progress through the four stages of psychological safety, particularly in fostering open dialogue and providing constructive feedback. This session introduces TeamSPEAK™, an initiative by Singapore’s largest healthcare cluster dedicated to promoting psychological safety and fostering open communication. This comprehensive approach enhances effective communication, reinforces positive change, and advances the organization through the stages of psychological safety. Coupled with TeamGRACE™, a locally developed program promoting professional behavior, civility, and communication among staff to achieve positive workplace culture and improve trust. We aim to cultivate an environment where transparent communication not only enhances safety but also drives continuous improvement and sustainable quality in patient care. Join us to discover practical strategies and real-world examples of how fostering psychological safety can transform healthcare environments, improve team dynamics, and lead to sustainable quality improvements.

Key session outcomes: 

1. Understand the four stages of psychological safety and their impact on team dynamics.
2. Acquire practical skills to promote psychological safety within teams.
3. Develop strategies to foster a psychologically safe environment that supports sustainable quality improvement.

Alvin Chang KK Women’s and Children’s Hospital; Singapore
Pang Nguk Lan KK Women’s and Children’s Hospital; Singapore

 

Part 3: Getting through Fear of Blame to Reporting and System Learning – Our Journey in Increasing Near-Miss Reporting

Tan Tock Seng Hospital is one of the largest tertiary hospitals in Singapore. Over the years, we worked on promoting a culture where hospital staff can share information openly and are given fair treatment when an incident happens. We established a second victim support program where staff involved in a serious adverse event are provided support based on a tiered model. The fear of blame is a common barrier to incident reporting. A Good Catch Program was co-created with frontline staff to recognise people who prevented errors from causing harm. We have achieved a sustained increase in near miss reporting. This enabled us to be more pro-active in system gap identification and closure before patients are harmed. This session is for healthcare practitioners at every level seeking to understand how to improve safety culture and near miss reporting.

Key session outcomes: 

1. Understand how a Just Culture tool can be used jointly with the Decision Tree for Determining Culpability of Unsafe Acts, to ensure balanced accountability for staff and organization whilst allowing the need for an open and honest reporting environment.
2. Appreciate how a Just Culture tool helps the supervisors to evaluate the incident without bias or judgment and provide fair treatment to staff, whilst learning from the incident and fixing the underlying system issues to provide a safe environment for patients.
3.Understand how an organization can provide a formal support structure to staff following an adverse event. Understand how the implementation of a Good Catch Program and error communication contribute to system improvement through learning from near miss reporting

Tan Hui Ling Tan Tock Seng Hospital; Singapore