In this publication, the National Institute of Justice (NIJ) explores the feasibility of mobilizing an “organizational accident,” learning-from-error approach in the criminal justice system. We introduce the notion of the “sentinel event”: a bad outcome that no one wants repeated and that signals the existence of underlying weaknesses in the system.
This report reviews the lessons learned by three forward-leaning teams in their review of a negative criminal justice outcome ("sentinel event") in their jurisdictions. The project represents the next step in NIJ's exploration of the feasibility of using sentinel event reviews as a way to learn from errors in the criminal justice system. See also 029617.