U.S. Department of Justice

Mending Justice: Sentinel Event Reviews

Publication year: 2014

Library ID

  • 029617

Other Information

  • 2014
  • 68 pages
"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." Essays contained in this publication are: "Learning From Error in the Criminal Justice System: Sentinel Event Reviews" by James M. Doyle (primary essay); "Moving Beyond a Culture of Defensiveness and Isolation" by John Chisholm; "To Learn Something, Do Something" by Michael Jacobson; "No Sticks: Safe Spaces and a Desire to Get Ever Better" by Maddy deLone; "The Dilemma of the Moral Imperative" by Bernard Melekian; "Front-end and Back-end Solutions" by Dan Simon; "Stepping Back to Move Forward: Recognizing Fallibility and Interdependency" by Mark Houldin; "Egg Heads Matter: Academic/Agency Partnerships and Organizational Learning" by Jack R. Greene; "An Opportunity We Cannot Afford to Lose" by Greg Matheson; "The Blame Game" by Jennifer Thompson; "Innocence Commissions: The Case for Criminal Justice Partnerships" by Russell F. Canan; "High Expectations, Good Intentions and Normalized Policy Deviation: A Sentinel Event" by Jim Bueermann; "Using Sentinel Events to Promote System Accountability" by George Gascón; "Cold Case Homicides: Ideal Candidates for a Sentinel Event Review" by Frank P. Tona; "Building a Learning-From-Error Culture in Policing" by John R. Firman; "Punishment-Based vs. Education-Based Discipline: A Surmountable Challenge?" by Sean Smoot; and "Reducing Failure: A View of Policing Through an Organizational Accident Lens" by Jon Shane.