“Sentinel Events:” Learning From Mistakes/Errors

A bright light for Police — Sentinel Events.

• Listen to an audio presentation of the topic by NIJ Fellow James Doyle:

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. Read an article about NIJ’s development of the Sentinel Events Initiative.

“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?
   

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• Read the full article HERE.