Less than a week after completion of the course I am amazed how I have began to look at situations at work in a new light. As I see a safety issue that has occurred, individuals are often quick to look and point fingers. I am able to look past who did it but rather dig deeper into better understanding the system and how the system failed. It truly will take a great deal of time to change current outdated RCA process at our hospital. Furthermore, it is important to inspire the entire healthcare team to look and study all aspects of a safety event prior to drawing up a single cause.
During this new academic year I plan to become a resident member of the current RCA team. I hope that with small changes I can make strides to revolutionizing the RCA process into an event review process.
It truly was an amazing experience to attend Telluride. I look forward to continued conversations with this Telluride family for years to come and look forward to the changes we all can make towards improving patient safety.