An experienced panel from quality, clinical nursing, legal, risk management, and administration will present a Sentinel Event case study addressing the role of the bedside nurse and nursing leadership, especially in debriefing, striving for a culture of no blame while conducting a root cause analysis. The panel will identify effective methods to mitigate Sentinel Events. Strategies for forming a cohesive team to address the event and identify processes to prevent future occurrences will be discussed. In addition, there will be a discussion of the aftereffects of a Sentinel Event, including the emotional components from the moment of the Sentinel Event through the investigation process and resolution.