This document presents the National Institute of Justice’s (NIJ’s) Sentinel Events Initiative Strategic Research and Implementation Plan (SEI), which describes its current and projected efforts to explore, develop, and evaluate a mechanism for learning from error in criminal justice policies and practices.
A “sentinel event” is defined as a significant, unplanned adverse outcome within a system or process, possibly stemming from underlying weaknesses in the system that are likely the result of compound errors that could be addressed to prevent a recurrence of the adverse event or outcome. Some examples of sentinel events in criminal justice are the wrongful arrest or conviction of an innocent person and a death or injury of a person while in custody. A sentinel event can also be a “near miss,” meaning that an adverse event could have occurred except for last-minute extraordinary actions or the identification of impending error. The SEI presented in this report sets three strategic priorities in building a reliable infrastructure for identifying sentinel events and instituting reforms based on their their subsequent analysis. One SEI strategic priority is to advance the concept of learning from errors in criminal justice. A second strategic priority is to understand contextual drivers and barriers, and then identify promising practices for sentinel event reviews. The third strategic priority is to explore the adoption of evidence-based sentinel event reviews and their evaluations. For each of these strategic priorities, an action plan composed of a series of objectives is proposed. 9 notes
Date Published: February 1, 2017