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Creating a Culture of Safety: Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities

NCJ Number
Date Published
December 2016
33 pages
This report provides guidance on what correctional agencies can learn from other fields in countering suicide and self-harm among residents of correctional facilities, notably the health community's and the aviation community's practice of viewing adverse outcomes in their fields as "sentinel events" that require a reassessment of their systems and practices so as to prevent similar adverse outcomes in the future.
This report embraces the protocol of conducting an all-stakeholder, non-blaming, forward-looking, and reformative review process of every incident of suicide or attempted suicide or of self-harm involving a correctional facility resident. This "sentinel event" approach resists blaming individuals for the event, as it encourages an ethic of shared responsibility in which all parties examine the various factors that contributed to the occurrence of the sentinel event. This is followed by the development and implementation of changes in facility policies and practices that will counter the factors believed to have led to the sentinel event. Steps outlined for such a protocol are to identify the sentinel event; convene a multidisciplinary team; describe the event/create a timeline; identify contributing factors; identify the root causes; develop an action plan; share lessons learned; and measure the success of corrective actions. Some potential challenges for implementation of this review process in correctional facilities are categorized as logistical, interactional, and structural challenges; confidentiality concerns; and concerns about legal liability. 65 notes and a list of resources

Date Published: December 1, 2016