NIJ's Sentinel Events Initiative
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"Sentinel Events" and Criminal Justice System Errors
When bad things happen in a complex system, the cause is rarely a single act, event or slip-up. More often, bad outcomes are "sentinel events."
A sentinel event is a significant negative outcome that:
- Signals underlying weaknesses in the system or process.
- Is likely the result of compound errors.
- May provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.
As NIJ Visiting Fellow James Doyle has written:
"The conviction of the wrong person is never the exclusive responsibility of a lone "bad apple"; it is always an "organizational accident." No individual mistake is enough to create independently an organizational accident; small errors have to combine with each other — and with latent system weaknesses — before the tragedy can be completed. The correct answer to the question, "Who is responsible for this wrongful conviction?" is almost invariably "Everyone involved, to one degree or another," if not by making a mistake, then by failing to catch one. And "everyone involved" may include not only cops, forensic scientists, and lawyers at the sharp end of the system, but also legislators, policy makers, funders, and appellate judges far from the scene of the event who dictated the conditions under which the sharp-end operators work." 
NIJ's Sentinel Events Initiative borrows extensively from medicine and aviation (and other industries) where a blame-placing, backward-looking review process is yielding to a more forward-thinking, non-blaming, problem-solving approach. As in these other fields, significant advances in criminal justice processes may be achieved through the combined efforts of researchers, system analysts and the broad span of practitioners whose work is inextricably linked to the occurrence of error — and the eventual strengthening of the system and the prevention of future system errors.
Sentinel Events "Beta" Pilot Project
In April 2014, NIJ selected three jurisdictions — Milwaukee, Philadelphia and Baltimore — to serve as "beta" pilot sites to help explore the viability of conducting an all-stakeholder, nonblaming review of a sentinel event. NIJ, in partnership with the Office of Justice Programs Diagnostic Center, is providing limited technical assistance but no grant funds to these sites. The sites will conduct a review of a self-nominated sentinel event; the review teams vary among the sites but generally involve representatives of the prosecutor's office, the police department, the defense bar, victims or community interests, and city leadership.
NIJ's goal is to determine the feasibility of a sentinel events approach for learning from errors in the criminal justice system. Lessons learned from these pilot sites will be incorporated into subsequent NIJ Sentinel Events Initiative activities, including the possibility of a multisite demonstration field research grant program in 2015.
Funding for Sentinel Events Research
NIJ released a formal solicitation for research proposals in 2014. The deadline for applications is May 22, 2014.
With this solicitation, NIJ seeks proposals for research that can add to our understanding of how the concept of sentinel events can be used to improve the functioning of the criminal justice system. Funding under this solicitation will support multiple awards for either basic research or for applied studies (including evaluations). Though NIJ acknowledges that some projects involving field research may be more costly, NIJ anticipates that many relevant basic research projects could be supported at more modest funding levels. This is an open solicitation and all high-quality research proposals regarding some aspect of sentinel events pertaining to the criminal justice system will be considered.
Learn More About NIJ's Sentinel Events Initiative
- "NIJ’s Sentinel Events Initiative: Looking Back to Look Forward," James Doyle, NIJ Journal, 273, March 2014.
- Proceedings from the NIJ Roundtable on Sentinel Events, May 21-22, 2013.
- "Learning from error," James Doyle, in Police Foundation’s Ideas in Policing, No. 14, May 2012.
- "The Wrong Patient (pdf, 8 pages)," Exit Notice [opens in pop-up window] Mark Chassin and Elise Becher, Annals of Internal Medicine, Volume 136, Number 11, June 2002 .
- Learning from Error in Policing: A Case Study in Organizational Accident Theory, Jon Shane, 2013. Available for purchase from booksellers.
- "Learning from error in American criminal justice (pdf, 40 pages)," Exit Notice [opens in pop-up window] James M. Doyle, Journal of Criminal Law and Criminology, Volume 100, No. 1, 2010.
 Doyle, James. M., "The Prospects For Learning From 'Sentinel Events' In American Criminal Justice," Report to the National Institute of Justice, grant number 2011-IJ-CX-K060, forthcoming.
Date Modified: April 4, 2014