Notification of sentinel events is outlined in the Risk Management Program. A suspected sentinel event is brought to the immediate attention of the QI Coordinator and to the Chief of the Department, who decide if a sentinel event has occurred. If it is determined that the event is a sentinel event, a specialized team is assigned to perform a Root Cause Analysis (RCA) and report findings to Medical Management and the Quality Improvement Counsel Committee which implements the recommendations of the RCA to prevent reoccurrence.