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National Institute of Justice Sentinel Events Initiative All-Stakeholder Forum

NCJ Number
Date Published
National Institute of Justice
This report summarizes the key conclusions, recommendations, and considerations of the National Institute of Justice’s (NIJ’s) Sentinel Events Initiative All-Stakeholder Forum, which focused on how the criminal justice system can learn from error (“sentinel event”).
The forum was held in June 2017 and was attended by nearly 100 federal, state, and local criminal justice practitioners, researchers and academics, policymakers, crime survivors, community representatives, and federal partners. The forum explored 1) the potential benefits of aiding state and local criminal justice systems in developing the capacity for local sentinel event reviews (SERs); 2) how lessons learned from SERs in the medical and aviation fields might be applied in criminal justice; 3) existing research on SERs in criminal justice and related fields; 4) the kind of technical assistance needed to support local system wide reviews; and 5) the creation of a shared understanding of common goals and anticipated products from SERs that allow for local variation. This report presents an overview of the key recommendations and considerations developed by the forum. One of the recommendations is that the technical assistance provider have a pivotal role in promoting peer-to-peer learning, ensuring active participation, explaining the concepts of group dynamics, and encouraging subject-matter experts to participate in an SER. Another recommendation is that SERs focus on cases in which liability has already been determined and that all parties agree constitutes a sentinel event. Unanswered questions identified by the forum include how the recommendations will be implemented, how public and transparent the SERs should be, and how best to manage liability complications in the reviews.
Date Created: October 26, 2017