The successful implementation of sentinel event reviews (SERs) in medicine and aviation offers promising evidence for those who believe SERs could improve justice outcomes. It is important to keep in mind, however, that the criminal justice system presents unique challenges.
Both medicine and aviation have national-level bodies charged with ensuring that all-stakeholder, nonblaming reviews are performed after a negative event. No similar nationwide — or even state-level — facility exists within the highly fragmented criminal justice system. Therefore, NIJ continues to explore ways to identify and test effective strategies to convene, support and lead SERs.
Another challenge in implementing SERs in the justice system is the reality in which many officials operate. Police chiefs, sheriffs, prosecutors and corrections leaders do their jobs within an inherently political context.
"Although an SER process that identifies and corrects system failures may improve public safety and enhance justice, it also carries the risk of public scrutiny and criticism," said Mallory O'Brien, who led the Milwaukee team in the NIJ beta project.
Other findings from the NIJ beta project about the challenges of instituting SERs in the criminal justice system include the following:
- Ensuring that members of the SER team understand each other's agencies and how they operate.
- Policy or practice recommendations may be beyond the scope of agency leadership to effect, and some changes may require legislative action.
- Because laws drive the criminal justice system, it is often resistant to using the scientific method.
"It is important to remember, however, that when any system is introduced to a new idea, there will be challenges to its successful implementation," said Jessica Shaw, a current NIJ Fellow. "Even when the new idea has shown success in other venues — such as in medicine and aviation, in this case — the stakeholders in the new system may perceive it to be incompatible or too complex to work."
Shaw notes that organizational-change research also shows that even when a new idea seems rather straightforward in its logic or conceptual process — for example, shifting from "blaming and shaming" to a system improvement perspective — stakeholders can be resistant.
Although both real and perceived challenges demand explicit attention and realistic expectations, NIJ's beta project showed promising results. A number of SER team members in the three beta sites said that the review was personally and professionally gratifying, offering them a chance to learn from other people in the criminal and juvenile justice bureaucracy.
As one beta team member put it, "These types of case studies are where the organizational learning takes place."
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.