"Sentinel Events" and Criminal Justice System Errors
In Fiscal Year 2014, NIJ intends to fund research on the challenges of criminal justice "system errors" and the role of "sentinel events" to implement a forward-thinking, non-blaming, all-stakeholders approach to improving the functioning of the justice system.
On this page find:
Overview of Sentinel Events
In May 2013, NIJ convened a roundtable of experts to discuss the potential applicability of a "sentinel-events" approach to improving criminal-justice outcomes. Read a summary of the roundtable.
When bad things happen in a complex system, the cause is rarely a single act, event, or slip-up. More often, bad outcomes are "sentinel events."
A sentinel event is a significant negative outcome that:
- Signals underlying weaknesses in the system or process.
- Is likely the result of compound errors.
- May provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.
As NIJ Visiting Fellow James Doyle has written:
"The conviction of the wrong person is never the exclusive responsibility of a lone "bad apple"; it is always an "organizational accident." No individual mistake is enough to create independently an organizational accident; small errors have to combine with each other — and with latent system weaknesses — before the tragedy can be completed. The correct answer to the question, "Who is responsible for this wrongful conviction?" is almost invariably "Everyone involved, to one degree or another," if not by making a mistake, then by failing to catch one. And "everyone involved" may include not only cops, forensic scientists, and lawyers at the sharp end of the system, but also legislators, policy makers, funders, and appellate judges far from the scene of the event who dictated the conditions under which the sharp-end operators work." 
The notion of sentinel events borrows extensively from medicine and aviation (and other industries) where a blame-placing, backward-looking review process is yielding to a more forward-thinking, non-blaming, problem-solving approach. As in these other fields, significant advances in criminal justice processes may be achieved through the combined efforts of researchers, system analysts, and the broad span of practitioners whose work is inextricably linked to the occurrence of error — and the eventual strengthening of the system and the prevention of future system errors.
Planned Funding for Sentinel Event Research
NIJ will release a formal solicitation for applications later this year. In anticipation of the research solicitation, potential applicants will want to familiarize themselves with relevant background research papers, including:
- Proceedings from the NIJ Roundtable on Sentinel Events, May 21-22, 2013.
- "Learning from error," James Doyle, in Police Foundation’s Ideas in Policing, No. 14, May 2012.
- "The Wrong Patient (pdf, 8 pages)," Exit Notice [opens in pop-up window] Mark Chassin and Elise Becher, Annals of Internal Medicine, Volume 136, Number 11, June 2002 .
- Learning from Error in Policing: A Case Study in Organizational Accident Theory, Jon Shane, 2013. Available for purchase from booksellers.
- "Learning from error in American criminal justice (pdf, 40 pages)," Exit Notice [opens in pop-up window] James M. Doyle, Journal of Criminal Law and Criminology, Volume 100, No. 1, 2010.
 Doyle, James. M., "The Prospects For Learning From 'Sentinel Events' In American Criminal Justice," Report to the National Institute of Justice, grant number 2011-IJ-CX-K060, forthcoming.
Date Created: August 23, 2013