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.
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.
Funding for Sentinel Events Research
NIJ released a competitive solicitation in 2014 for research that will add to our understanding of how sentinel event reviews might be used to improve the functioning of the criminal justice system. NIJ made two 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 award.
- 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 award.
NIJ hopes to issue a solicitation for a multisite demonstration field research grant program in 2015.
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," 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.
Date Modified: April 4, 2014