NIJ's Sentinel Events Initiative

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What is a "Sentinel Event?"

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.

In criminal justice, a sentinel event might be a police shooting, the wrongful conviction of an innocent person, the release from prison of a dangerous offender, or even a “near miss” that could have led to a bad outcome had it not been caught.

Sentinel Event Reviews in the Criminal Justice System

Since 2011, we have been investigating the feasibility of using a sentinel event review approach to learn from errors in the criminal justice system. Sentinel event review has successfully been used in medicine, aviation and other high-risk enterprises. The overarching goal of sentinel event review is a routine, culture-changing practice that can lead to increased system reliability and, hence, greater public confidence in a system’s legitimacy.

Although most criminal justice agencies already have error-detecting procedures in place — police internal affairs reviews, for example, or prosecutors’ professional ethics boards — these often become “gotcha” processes that focus on assigning individual blame. This can drive the reporting of errors underground, making future errors even harder to detect and correct.

Sentinel event review is based on three underlying principles:

  • It is nonblaming.
  • All stakeholders — system-wide — are involved in the review.
  • It is an ongoing, routine practice.

Our Sentinel Events Initiative seeks to answer three empirical questions about using sentinel event reviews in the justice system:

  1. Can it be done?
  2. Does it have a positive impact, such as fewer errors and other public safety dividends, and increased public confidence in the nation’s justice system?
  3. Can it be sustained over time and incorporated into the routine activities of state and local justice processes?

In 2014, we published Mending Justice: Sentinel Event Reviews, which discusses sentinel event reviews in depth. The special report includes an introduction from former Attorney General Eric Holder and a number of commentaries from experts and other “early adopters” regarding the implementation of sentinel event review in the criminal justice system.

Testing Sentinel Event Reviews in Three Jurisdictions

In 2014, we asked jurisdictions from around the country to volunteer for an experiment — or beta test — of the sentinel event review process. Through a competitive process, three cities were selected: Milwaukee, Philadelphia and Baltimore.

The three sites designed and conducted their own review of a justice error (a sentinel event) that had occurred in their jurisdiction. By successfully completing a sentinel event review, the three sites provided the first empirical evidence of the feasibility of adopting sentinel event reviews in the justice system.

Lessons learned from the sites’ experiences are summarized in Paving the Way: Lessons Learned in Sentinel Event Reviews. This publication covers topics such as:

  • Where does a jurisdiction start when thinking about performing a sentinel event review?
  • What kind of an event should be reviewed, including some of the benefits and challenges of selecting an older event?
  • Who should be on the sentinel event review team — and who should lead or facilitate the review process?
  • How can the important ‘nonblaming’ component of sentinel event review be achieved?

Ongoing Research on Sentinel Event Reviews

Scientific research is key to developing evidence of how sentinel event reviews might be used to improve the functioning of the criminal justice system.

In 2014, we made two research awards:

  • Texas State University will use concept mapping and social network analysis to examine criminal investigative failures in wrongful convictions and unsolved cases. Learn more about the project.
  • Vera Institute of Justice will develop, implement and evaluate a Self-Harm Analysis and Review Protocol (SHARP) for responding to cases of serious self-harm in the New York City jail with the aim of designing a nationally replicable sentinel event review model. Learn more about the project.

In 2015, we made two research awards:

  • Researchers from Michigan State University — working with researchers from Indiana University and the director of the Milwaukee Homicide Review Commission — are delving deeper into the ongoing gun homicide and non-fatal shooting review processes in Milwaukee, Detroit and Indianapolis, establishing multiagency teams to study issues such as privacy, resources needed, and the role of the facilitator. Learn more about the project.
  • Researchers at the University of Pennsylvania’s Quattrone Center for the Administration of Fair Justice — in collaboration with the Philadelphia Police Department, District Attorney’s Office, Defender Association, and Court of Common Pleas — are evaluating the effectiveness of multidisciplinary review teams and includes creation of a database of errors and near-misses — similar to the Aviation Safety and Reporting System used in aviation industry — to help prioritize negative outcomes for sentinel event review. Learn more about the project.

Learn More About Sentinel Events Reviews

Date Modified: November 5, 2015