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Instilling a Culture of Continuous Learning From Criminal Justice System Errors: A Multi-Stakeholder Sentinel Event Review of Process in Philadelphia

Award Information

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Total funding (to date)

Description of original award (Fiscal Year 2015, $351,052)

The proposed research will evaluate the ability of a multi-stakeholder (i.e., cross-agency) Sentinel Events review team consisting of police, prosecutors, defenders, judges, City government, and others in a large urban jurisdiction. The review team will create a cross-agency database of cases of error or "near misses" throughout the jurisdiction's criminal justice system, and will met regularly to prioritize and evaluate cases that are Sentinel Events and/or more routinized errors in the administration of criminal justice. Our research will closely observe and report on the structure, activities, and governance necessary to conduct and optimize the team's multi-stakeholder Sentinel Event reviews over time, and will evaluate the impact of the review team and its ability to implement modified policies, procedures and practices within its participating agencies to reduce and/or prevent those errors going forward. The database of unintended outcomes or "near misses" will allow for the thoughtful prioritization of cases for review as well as enabling novel data analyses of errors and potential preventative steps. We will also conduct an evaluation of the process and impact of a Sentinel Events Review team that spans multiple stakeholders in the administration of criminal justice (law enforcement, prosecutors, defense bar, judiciary, and others as needed) as well as existing administrative oversight bodies (e.g., the Philadelphia Criminal Justice Advisory Board) over time. By the end of the period of performance, the research will yield a wealth of scholarly work suggesting strengths, weaknesses, "best practices," preferred methodologies, and impact of multi-stakeholder Sentinel Event reviews for learning from and addressing errors in criminal justice systems that further NIJ's goals in issuing this solicitation. This project contains a research and/or development component, as defined in applicable law.

This project contains a research and/or development component, as defined in applicable law.


Date Created: September 27, 2015