Mending Justice: Sentinel Event Reviews

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How should the criminal justice system respond to errors?

A common response is to seek out “bad apples,” apportion blame, and conclude that the error has been dealt with once that individual is punished or a policy is changed.

But errors in a complex system 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 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 in the future and improve overall system reliability.

Mending Justice: Sentinel Event Reviews explores the potential to learn from errors in the criminal justice system by applying a sentinel event review approach.

The primary essay — written by James Doyle, a Visiting Fellow with NIJ for two years — discusses how principles used by aviation and medicine to improve outcomes could be adopted in criminal justice.

The book includes a message from the Attorney General and 16 commentaries from highly respected representatives of criminal justice researchers, practitioners and other stakeholders.

Jump directly to specific sections of the book:

• Message from the Attorney General
• Introduction
• Essay by James Doyle, “Learning From Error in the Criminal Justice System: Sentinel Event Reviews”
• CommentariesJohn Chisholm, “Moving Beyond a Culture of Defensiveness and Isolation”
• Michael Jacobson, “To Learn Something, Do Something”
• Maddy deLone, “No Sticks: Safe Spaces and a Desire to Get Ever Better”
• Bernard Melekian, “The Dilemma of the Moral Imperative”
• Dan Simon, “Front-end and Back-end Solutions”
• Mark Houldin, “Stepping Back to Move Forward: Recognizing Fallibility and Interdependency”
• Jack R. Greene, “Egg Heads Matter: Academic/Agency Partnerships and Organizational Learning”
• Greg Matheson, “An Opportunity We Cannot Afford to Lose”
• Jennifer Thompson, “The Blame Game”
• Russell F. Canan, “Innocence Commissions: The Case for Criminal Justice Partnerships”
• Jim Bueermann, “High Expectations, Good Intentions and Normalized Policy Deviation: A Sentinel Event”
• George Gascón, “Using Sentinel Events to Promote System Accountability”
• Frank P. Tona, “Cold Case Homicides: Ideal Candidates for Sentinel Event Review”
• John R. Firman, “Building a Learning-From-Error Culture in Policing”
• Sean Smoot, “Punishment-Based vs. Education-Based Discipline: A Surmountable Challenge?”
• Jon Shane, “Reducing Failure: A View of Policing Through an Organizational Accident Lens”
• Appendix

Learn more about:

• Precursors from Medicine and Aviation (pdf, 2 pages)
• Tools for Evaluating Field Receptivity to a Sentinel Events Approach (pdf, 2 pages)

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