Sentinel Events: A Sustainable Model for System Change

The proposed study seeks to implement sentinel review processes in three jurisdictions and to study the feasibility and utility of employing sentinel reviews in criminal justice settings. The study builds on review processes already in existence in three cities (Detroit, Indianapolis, and Milwaukee). Specifically, gun homicide (GH) and non-fatal shooting (NFS) reviews occur in these three cities with the goal of developing data-driven gun violence prevention and control strategies. Additionally, under a current NIJ award (2013-R2-CX-0015), the Co-Principal Investigators are studying how these review processes improve our understanding of firearms violence. As will be described subsequently, the gun homicide and non-fatal shooting review process (HNFS-R) already underway has identified a sub-set of homicides and non-fatal shootings that represent sentinel eventsnegative events that appear to reflect system failure. The proposed study seeks to first identify a number of these sentinel events and to implement a complementary sentinel event review process. The complementary review process will study these sentinel events to identify system failures or breakdown in processes that resulted in the negative event through Root Cause Analysis (RCA). The study will involve a cross-city comparison of the sentinel review process as well as an experimental examination of the different approaches to reporting the results from the sentinel review. The goals of the study include advancing knowledge about sentinel events and the sentinel review process, including an assessment of the utility of the review process for identifying, analyzing, and addressing system failure. The assessment will also identify obstacles in implementing sentinel reviews. Outcomes will include peer-reviewed publications to inform the scientific community, policy-relevant reports focused on the transfer of the lessons learned to the criminal justice professional community, development of schematic processes for assessing sentinel reviews in other criminal justice contexts (e.g., wrongful convictions), and sample sentinel review reports informed by the findings of the experiment conducted as part of this study. This project contains a research and/or development component, as defined in applicable law. ca/ncf