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A Glimpse at Ongoing Sentinel Event Review Research Projects

Date Published
December 13, 2015

Sidebar to the article Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice? by Nancy Ritter.

As part of building the evidence base for bringing sentinel event reviews (SERs) into the justice system, NIJ is supporting four major research projects. Here's a glimpse of the ongoing work:

  • Texas State University is using concept mapping and social-network analysis to look at investigative failures in wrongful convictions and unsolved cases. Failures in law enforcement investigation are sentinel events, which could signal underlying structural problems throughout the entire criminal justice system. The researchers, funded in 2014, are deconstructing wrongful convictions to determine the contributing causal factors — essentially, what went wrong and why. These causal factors will be classified as personnel issues (such as "tunnel vision" or inexperience), organizational problems (such as "groupthink" or insufficient agency resources), or situational features (such as poor community cooperation). The researchers will then build concept maps to graphically display the relationships and interactions between the causal factors. Based on these analyses, they will make recommendations for improvements in criminal justice policies and organizational procedures.
  • The Vera Institute of Justice is working with the New York City Department of Correction and Department of Health and Mental Hygiene to develop, implement and evaluate a protocol for reviewing and responding to cases of serious self-harm in the New York City jail. Suicides and incidents of self-harm among people in jail are sentinel events that signal a breakdown in the corrections system's ability to ensure inmate health and safety. Most jails, however, do not have adequate processes for reviewing these incidents and taking corrective action based on those reviews. Funded in 2014, the researchers are using several data-gathering methods to create a protocol called SHARP (the Self-Harm Analysis and Review Protocol), including examining morbidity and mortality reviews, surveying correctional and mental health staff, and analyzing administrative data to determine the predictors of self-harm. They will then assess whether SHARP resulted in tangible changes to jail policies and practices. The overarching goal of the project is to create a nationally replicable SER model.
  • In 2015, NIJ funded researchers from Michigan State University — who have teamed up with researchers from Indiana University and the director of the Milwaukee Homicide Review Commission — to delve deeper into gun homicide and nonfatal shooting review processes in Milwaukee, Detroit and Indianapolis. Multiagency teams will be established in each of these three cities to review approximately 12 sentinel events per city per year during the three-year project. The researchers will also investigate the use of SERs in medicine and aviation to help ensure that the criminal justice system benefits from lessons learned in these fields. For example, the researchers — all of whom have strong ties to public health — will explore the applicability to criminal justice of the "root cause analysis" questions that the Joint Commission developed for SER in the medical field.
  • In 2015, NIJ funded the University of Pennsylvania Law School's Quattrone Center for the Fair Administration of Justice, which is working with the Philadelphia Police Department, District Attorney's Office, Defender Association and Court of Common Pleas, to evaluate the effectiveness of multidisciplinary SER teams. The goal of the three-year project is to implement a sustainable multi-stakeholder process for identifying, prioritizing and conducting SERs that improve the administration of justice and that can be replicated in other jurisdictions. The project will create a database of errors and near-misses similar to the Aviation Safety and Reporting System, providing a mechanism for prioritizing negative outcomes or "cases of error" suitable for SER. The overarching goal is to develop rules and standards for constructing, managing and maintaining multi-stakeholder teams that help each stakeholder agency — and the criminal justice system as a whole — embrace SER as part of a culture of learning from error.

About This Article

This artice appeared in NIJ Journal Issue 276, December 2015, as a sidebar to the article Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice? by Nancy Ritter.

Date Published: December 13, 2015