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 Director’s Corner: How We Can Learn From Errors Within Criminal Justice
Archival Notice
              This is an archive page that is no longer being updated. It may contain outdated information and links may no longer function as originally intended.
Date
              January 31, 2017
Speaker
              Howard Spivak, MD
Every year, there are millions of interactions between the public and the criminal justice system. Most of those interactions result in a legitimate or just outcome. However, that is not always the case. In the relatively rare instances when the outcome is not legitimate or just, it can be devastating for individuals, families, communities, and criminal justice professionals.

As with any complex system of agencies, the criminal justice system is complex, has flaws, and requires mechanisms to understand these outcomes and prevent them from recurring.

What Is a Sentinel Event?

A sentinel event is a significant, unexpected negative outcome that

Signals possible underlying weaknesses in a system or process.
	Is likely the result of compound errors.
	May provide keys to preventing future adverse events or outcomes.A police-citizen encounter that unexpectedly turns violent. The release from prison of a person who quickly reoffends. In-custody deaths or injuries including self-harm and suicide in prisons. The wrongful arrest or conviction of an innocent person. Violations of an individual’s right to a speedy trial. Ineffective assistance of counsel or lack of access to sufficient legal assistance. Unreasonable delays in forensic evidence processing. A sentinel event could also include a “near miss” event, one in which a bad outcome may have occurred but for extraordinary actions of an individual or a last-minute identification of the impending error by an individual or system process.Through the Sentinel Events Initiative, NIJ is focused on learning from system weaknesses in criminal justice and teaching the culture to be more focused on transparency and committed to continual improvement.

The Sentinel Events Initiative examines:

If systematic review of errors, or sentinel event reviews, can be implemented and routinized in a criminal justice context.
	If these reviews will inform policy and practice improvements to mitigate the risk of analogous errors or weaknesses in the future.
	If these reviews are sustainable over time.You can learn more about the theory behind sentinel event reviews in Mending Justice: Sentinel Event Reviews.

However, because sentinel event reviews are rare in criminal justice, NIJ must develop and implement the program it seeks to examine, infusing scientific assessments and evaluations throughout the process.

I am proud to announce the release of the *NIJ Strategic Research and Implementation Plan: Sentinel Events Initiative* [link]. This plan outlines the development, implementation, and broad adoption of a rigorous sentinel event review approach that not only reveals system weaknesses, but also identifies high-priority areas where further scientific exploration can support system improvements.

Through this strategic plan, NIJ is committed to building on our previous investments in the Sentinel Events Initiative and collaborating with and leveraging related efforts to improve the criminal justice system. From efforts to strengthen the forensic sciences to those focused on more effective policing and community engagement, stakeholders across the system are demonstrating a commitment to identifying system weaknesses, learning from them, and using them to improve the administration of justice.

To help spread the adoption of sentinel event reviews, we are also partnering with our Office of Justice Programs sister agency, the Bureau of Justice Assistance, to support a technical assistance provider. This provider will help establish and support approximately 30 sentinel event review sites across the country. The nationwide endeavor will result in the development, implementation, and routinization of non-blaming, forward-looking, multi-stakeholder reviews at the jurisdictional level, as well as a process evaluation to identify promising practices and common challenges to implementation.

The establishment of these sites is the latest step in the Sentinel Events Initiative and builds upon years of scientific research as well as the pilot testing of sentinel event reviews. In 2014, NIJ supported three jurisdictions — Milwaukee, Philadelphia, and Baltimore — to test the sentinel event review process. The cities designed and conducted their own review of an error, or near miss that had occurred in their jurisdiction. These reviews provided the first empirical evidence of the feasibility of adopting a sentinel event review approach in the justice system. Lessons learned from the sites’ experiences are summarized in Paving the Way: Lessons Learned in Sentinel Event Reviews.

In addition to supporting these pilot sites, NIJ has invested in scientific research to better understand errors within the justice system and how to implement sentinel event reviews. These projects have examined criminal investigative failures in wrongful convictions and unsolved cases, supported the development of a SER approach in corrections, and examined how ongoing gun homicide and non-fatal shooting review processes in three cities further our understanding of the potential outcomes and benefits of sentinel event reviews.

We also have supported the implementation and evaluation of a sentinel event review approach in several jurisdictions and police departments over time to test the sustainability of sentinel event reviews. Learn more about the awards made under the Sentinel Events Initiative.

We realize that an approach of this magnitude — particularly one that may indicate a seismic shift in how criminal justice stakeholders approach errors, transparency, and collaboration — will require sustained investment and commitment from professionals across the criminal justice system and researchers dedicated to understanding how best to implement sentinel event reviews.

This strategic plan is just one step forward in NIJ’s goal to minimize preventable harm and improve public safety. I hope you will join us in our efforts.
    
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