Opportunity to Host a Town Hall Meeting for Preventing Underage Drinking

Sentinel Events Initiative

 

Beginning in 2011, the National Institute of Justice  (NIJ), the research, development, and evaluation agency of the U.S. Department of Justice, has been exploring the feasibility of using a learning-from-error approach in the criminal justice system by conducting sentinel event reviews (SERs). James Doyle, a Visiting Fellow at NIJ from 2012 to 2014, explains that when bad outcomes occur in a complex social system, such as the criminal justice system, it is rarely due to a single act or mistake. Generally, it is the combination of small errors throughout a system that lead to these bad outcomes, or sentinel events. A "sentinel event":

Examples of a sentinel event in the criminal justice system include a police shooting, "near miss" acquittals and dismissals of cases that at earlier points seemed solid, wrongful convictions, or the erroneous release from prison of a dangerous offender. The  Final Report of The President's Task Force on 21st Century Policing  (p. 22) includes the following recommendation: "Law enforcement agencies are encouraged to implement nonpunitive peer review [sometimes known as "near miss" or "sentinel event" reviews] of critical incidents separate from criminal and administrative investigations."

 

An SER is a non-blaming, ongoing, and routine practice involving stakeholders. Successfully implemented in other professions, the goal of SERs is to better understand how events happened and use the findings to make practice and policy improvements and prevent similar bad outcomes in the future. In 2014, NIJ published Mending Justice: Sentinel Event Reviews (PDF) that explores the potential to learn from errors in the criminal justice system by applying an SER approach. The special report includes an introduction from Attorney General Eric Holder and 16 commentaries from criminal justice researchers, practitioners, and other experts and "early adopters" regarding the implementation of SERs in the criminal justice system. In Jack R. Greene's essay, "Egg Heads Matter: Academic/Agency Partnerships and Organizational Learning," (p. 32) he suggests "universities and colleges, as producers and disseminators of knowledge, can play an important role in these matters - first by assessing sentinel events, systematically and independently, and then convening discussions within and across agencies about the findings of such assessments." 

 

NIJ selected three pilot sites, Milwaukee, Philadelphia, and Baltimore, through a competitive process in 2014 as beta test sites for exploring the SER process. In 2015, NIJ published  Paving the Way: Lessons Learned in Sentinel Event Reviews (PDF), which serves as a companion piece to Mending Justice: Sentinel Event Reviews and includes empirical evidence gathered from SERs conducted on justice errors in these jurisdictions.

 

Visit NIJ's Sentinel Events Initiative website to learn more, access additional articles and publications, and to subscribe to receive e-mail updates about NIJ's Sentinel Events Initiative.