New Policy??

So a hypothetical situation here...This is a homework question with a quick answer! Yes, I googled it but I must not be using the right search term because I can't find the answer. Anyway, say a child was released post op to her non custodial father, creating a JCAHO sentinel event. In my action plan I, of course, included the need for yet another new policy. Now, who would be the one to actually develop that policy? Would it be legal, risk, admitting, CEO/Admin, HR, or???

TY for your help

In the presence of a sentinel event there would be a root cause analysis where all staff and departments involved are present to see what went wrong and how to improve the process. These are not meant to be finger pointing pow wows but a fact finding get together to improve the rpocess. The department involved would begin the policy....let's say PEDI. The manager, staff, educator, director and medical chair would develop the early plan. Then Risk management and legal would get involved to try to idiot proof, I mean close loop holes in the policy. Then the policy would be presented to all department managers for approval or suggestions and finally to be approvd by nursing admin, CEO, medical MD chief's, and HR before entering the policy books.

There maybe slight variations from facility to facility but this is a pretty good representation!!