This special report from the National Institute of Justice explores the potential of using a "sentinel event" review approach to learn from errors in, and make improvements to, the criminal justice system; included in this report is a message from the Attorney General and commentaries from highly respected researchers, practitioners, and stakeholders.
A common response to the question of "how should the criminal justice system respond to errors?" is to seek out "bad apples," apportion blame, and conclude that the error has been dealt with once that individual is punished or policy is changed. However, errors in complex systems are rarely the result of a single act or event. In medicine, aviation, and other high-risk enterprises, serious errors are regarded as system errors or "organizational accidents." Organizational accidents are potential "sentinel events," incidents that could signal more complex system-wide flaws that threaten the integrity of the system as a whole. These other complex systems have developed sentinel event reviews nonblaming, all-stakeholder, forward-leaning mechanisms to go beyond disciplining rule-breakers in an effort to minimize the risk of similar errors occurring in the future and to improve overall system reliability.