U.S. flag
      An official website of the United States government, Department of Justice.
        Here's how you know
      Here's how you know**Official websites use .gov**
            
            A **.gov** website belongs to an official government organization in the United States.
      **Secure .gov websites use HTTPS**
            
            A **lock** (
            A locked padlock
            ) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. Menu

      
        close

            
            
                                              About NIJ
        
                    
  
          About NIJ
      
    
          The NIJ Director
          How NIJ Is Organized
          Mission and Guiding Principles
          Research and Development Process
          Strategic Framework
          Assessments of NIJ
          Annual Reports & Reports to Congress
          Staff Directory
          Funding & Awards
        
                    
  
          Funding & Awards
      
    
          Current Funding
          Forthcoming Funding
          Expired Funding
          Awards: Listing of Funded Projects
          Guidance for Applicants and Awardees
          Fellowship & Student Programs
          Travel Scholarships
          NIJ Challenge Program
          Library & Multimedia
        
                    
  
          Library & Multimedia
      
    
          NIJ Journal
          Podcasts
          Publications Listing
          Multimedia Listing
          Rated Practices on CrimeSolutions
          Rated Programs on CrimeSolutions
          Software & Databases
          Datasets
          Patents
          Topics
        
                    
  
          Topics
      
    
          Article Listing
          Corrections
          Courts
          Crime Prevention
          Crimes
          Drugs and Crime
          Equipment and Technology
          Forensic Sciences
          Youth Justice
          Justice System Reform
          Law Enforcement
          Tribal Crime and Justice
          Victims of Crime
          Events
        
                    
  
          Events
      
    
          NIJ 2024 Research Conference
          Scheduled Events
          On-Demand Events
          Research Meetings & Workshops
          NIJ-Hosted Online Training

                            
                                About
          Contact Us
          Subscribe
          Topics A-Z
                  Share
FacebookXLinkedInRedditPinterestEmail Home
                            Library & Multimedia
 Sentinel Events Approach to Jail Suicide and Self-Harm
NCJ Number
              254365

Author(s)
          Leah G. Pope;
                        Jason Tan de Bibiana
Date Published

June 2019
Length
              19 pages
Annotation
              This is the Final Summary Overview of the findings and methodology of a study that builds an evidence base for the feasibility of "sentinel event reviews" in the criminal justice system, with a focus on preventing suicides by jail inmates.
Abstract
              A "sentinel event" is defined as "a significant negative outcome that signals underlying system weaknesses, is likely the result of compound errors, and may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse outcomes." The "sentinel event review" is characterized by an all-stakeholder, non-blaming, and forward-looking examination of the error. It is an institutionalized approach that identifies root causes of a sentinel event and underlying systems failures. The current study drew on research in four county jail systems in answering three research questions: 1) How do the selected jail systems currently review inmate suicides and self-harm? 2) What challenges and successes have they experienced in developing multi-stakeholder reviews and corrective action plans in response to inmate suicides and self-harm? 3) How does the legal and policy landscape in each jurisdiction impact the feasibility of conducting sentinel event reviews in responding to inmate suicides and self-harm? Study results suggest that the design and implementation of any sentinel event review will involve multiple factors that range from how healthcare is delivered to inmates, communication processes in place, the organizational culture of the jail, and the legal system of the state where the jail is located. A forthcoming report from the researchers will provide recommendations for jail-based sentinel event reviews of inmate suicide based on the results of this study. 1 table and a listing of this study's reports and upcoming scholarly products
      
  
          Additional Details
Grant Number(s)
        2014-IJ-CX-0030


  
  
        
  Agencies
        NIJ-Sponsored


  
  
        
  Publication Type
        Research (Applied/Empirical)
                                Report (Summary)
                                Report (Study/Research)
                                Report (Grant Sponsored)
                                Program/Project Description


  
  
        
  Award
        A Sentinel Events Approach to Addressing Suicide and Self-Harm in Jail
    
  
  
Date Published: June 1, 2019
    
          Downloads
        
                      PDF

Side navigation
  

        

  
  
              NIJ Journal
    
      
            
            
            
      Podcasts
    
      
            
            
            
      Publications Listing
    
      
            
            
            
      Multimedia Listing
    
      
            
            
            
      Rated Practices on CrimeSolutions
    
      
            
            
            
      Rated Programs on CrimeSolutions
    
      
            
            
            
      Software & Databases
    
      
            
            
            
      Datasets
    
      
            
            
            
      PatentsRelated Topics
        
                Correctional reform
        Corrections
        Deaths in custody
        Inmate assistance programs
        Inmate suicide



  
Similar Publications
        
                      Laser Induced Breakdown Spectroscopy as a Tool for Discrimination of Glass for Forensic Applications
                  Direct-Injection Mass Spectrometric Method for the Rapid Identification of Fentanyl and Norfentanyl in Postmortem Urine of Six Drug-Overdose Cases
                  Agency and Social Constraint Among Victims of Domestic Minor Sex Trafficking: A Method for Measuring Free Will
 Top

      National Institute of Justice

        
        
                        About NIJ
                    About NIJ
      
    
                  How NIJ Is Organized
      
    
                  NIJ Director
      
    
                  Research Disclaimer
      
    
                  Funding & Awards
                    Funding & Awards Home
      
    
                  Awards Listing
      
    
                  Current Funding
      
    
                  Guidance for Applicants and Awardees
      
    
                  Resources
                    Events
      
    
                  Podcasts
      
    
                  Publications
      
    
                  Topics
      
    
                  Multimedia
      
    
                  Reuse Policy
      
    
                  Contacts
                    Contact NIJ
      
    
                  Staff Directory
      
    
                  Submit a FOIA Request
      
    
                  File a Civil Rights ComplaintFacebook
          
                      X
          
                      YouTube
  

      810 7th St. NW, Washington, D.C. 20531
      
              Secondary Footer link menu
            Accessibility
              Plain Language
              Privacy Policy
              Legal Policies and Disclaimer
              No FEAR Act
              Freedom of Information Act
              USA.gov
              Justice.gov