Through a competitive process, three cities were selected: Milwaukee, Philadelphia and Baltimore. In 2014, we asked jurisdictions from around the country to volunteer for an experiment - or beta test - of the sentinel event review process. Testing Sentinel Event Reviews in Three Jurisdictions Read the NIJ Strategic Research and Implementation Plan Sentinel Events Initiative. Findings from the activities that fall within this strategic research plan will be disseminated among constituents and partners in ways designed to achieve the greatest impact. As with all federal programs, this expansion is dependent on funding availability. This document will be of interest to researchers (academic, governmental, and industry) federal, state, and local government partners as well as justice policymakers, and its progress to date, and offers a roadmap for NIJ’s plans for expansion. NIJ developed the Sentinel Events Initiative Strategic Research and Implementation Plan to describe its current and projected efforts to explore, develop, and evaluate a mechanism for learning from error in criminal justice. Strategic Research and Implementation Plan 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. In 2014, we published Mending Justice: Sentinel Event Reviews, which discusses sentinel event reviews in depth. Can it be sustained over time and incorporated into the routine activities of state and local justice processes?.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?.Our Sentinel Events Initiative seeks to answer three empirical questions about using sentinel event reviews in the justice system: All stakeholders - system-wide - are involved in the review.Sentinel event review is based on three underlying principles: This can drive the reporting of errors underground, making future errors even harder to detect and correct. Read an article about NIJ's development of the Sentinel Events Initiative.Īlthough 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. 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. Sentinel event review has successfully been used in medicine, aviation and other high-risk enterprises. 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 Reviews in the Criminal Justice System Learn more about sentinel events by reviewing articles in our compiled sentinel events bibliography. 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 person or even a “near miss” that could have led to a bad outcome had it not been caught. ![]() May provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.Is likely the result of compound errors.Signals underlying weaknesses in the system or process.More often, bad outcomes are "sentinel events."Ī sentinel event is a significant negative outcome that: When bad things happen in a complex system, the cause is rarely a single act, event or slip-up. Learn More About the Sentinel Event Reviews.Testing Sentinel Event Reviews in Three Jurisdictions.Strategic Research and Implementation Plan.Sentinel Event Reviews in the Criminal Justice System.The Sentinel Events Initiative (SEI) is a joint project of the National Institute of Justice (NIJ) and the Bureau of Justice Assistance (BJA). The goal of this project is to empower jurisdictions to build capacity and ultimately conduct their own reviews, which will mitigate future risk and reduce costs. ![]() The Bureau of Justice Assistance's Sentinel Events Demonstration Project project provides technical assistance to jurisdictions seeking to conduct one or more sentinel event reviews. Sentinel Events Initiative Demonstration Project ![]()
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