A few months ago ABC Medical Center encountered a very serious event. The wrong limb had been surgically removed from a patient. The identification of the patient, the verification of the involved limb, and the time out procedure were all in place. How could this happen if protocol was followed? Today we will look at the challenges we face handling the sentinel event, strategies that could be used to tackle the conflict, suggestions for how these strategies can be implemented, the role collaboration has while implementing these strategies, the role of individuals and teams in this process. The risk management team has been working diligently to identify obstacles that might arise in the implementation, and how the team will overcome them. This facility will face many challenges while handling this serious event. Our first priority is the patient. How will we handle the impact this has on the patient and the patient’s family? It is difficult to honestly discuss an adverse event, but it demonstrates respect for the patient and commitment to improving care. Our next concern will be support for the staff. All reports of anadverse event must be reported within the facility to the patient safety manager and is protected from disclosure under 38 U.S.C. 5705, as part of the medical quality assurance program (PCM) (Reid, 2012). Our risk management team will decide what will be the appropriate action to take to handle the event. The team will crate and execute plans based on the list of control solutions (MetricStream Governance, Risk, Compliance, and Quality Management Solutions, 2012). Our legal team will be notified and will meet with the Director, risk manager, and all parties involved in preparation for the possible civil law suit. Tort claims result in settlement or judgment. The legal team will also have to conduct a review that may result in a recommendation to report the provider at fault to the National Practitioner Data Bank for professional incompetence. JCAHO requires the staff involved to attend training courses to enforce surgery protocol to prevent any future events. Our facility offers trauma and emotional support to the patient and family. A social worker will visit with the patient and family to offer emotional support and resources the patient will need in the near future. The hospital chaplain may also visit the patient and family to offer spiritual support. The chaplain may also offer emotional support to the staff. An outside counselor may be brought in to speak with the staff concerning the event. The risk management team will conduct a causation/risk analysis to find out what caused the adverse event and find ways to prevent future events. The risk analysis is a five steps process: 1. Identify the risk 2. Consider alternate risk techniques 3. Select the best technique 4. Implement the technique 5. Monitor and improve the process. The analysis helped to pinpoint where the break in the process was. It also helped the facility find ways to prevent this event from occurring again and continuing to monitor the process to improve it in the future.