Since 1995, The Joint Commission reviewed 7,000+ root cause analyses of sentinel events reported by accredited organizations. Since the inception of the Sentinel Event Policy, patient safety has evolved considerably beginning with the IOM report To Err is Human in 1999. The Joint Commission is developing Sentinel Event Policy changes that will encompass new thinking in patient safety: empowerment of front-line employees, leadership commitment, defined accountability, commitment to learning and an environment that fosters trust, communication and reporting. Participants will learn about the proposed direction and have input into the next iteration of The Joint Commissions Sentinel Event Policy.