One day, a staff psychiatrist was leaving work form the outpatient mental health building. He noticed a woman in the waiting areas who looked frail and felt something was not right. He called Unit 1A and asked Rachael Powers, a unit RN to investigate the situation. Ms. Powers walked over to the waiting area and recognized the woman as a former patient of hers. She knew that this person suffered from memory issues lived in a locked memory unit, and needed to be accompanied. She spoke with the woman and discovered that she was waiting for a cab. Ms. Powers called the cab company to confirm they were coming and then waited with the woman for 30 minutes until the cab arrived. She spoke with the cab driver and explained the situation, asking the driver to personally hand the woman off to staff at the nursing home. Ms. Powers waited a short time and then contacted the nursing home to ensure the woman had arrived safely. Had Ms. Powers not intervened, this could have resulted in a sentinel event. She took the initiative to ensure this Veteran was safe, going above and beyond her normal duties.