Sentinel Events Initiative Strategic Research and Implementation Plan
Download and print the full plan (pdf, 23 pages).
Mission of the Initiative
To explore the widespread adoption of sentinel event reviews, an evidence-based model for learning from error in the criminal justice system; to scientifically examine the feasibility, impact, and sustainability of this model; and to leverage diverse efforts to collaboratively learn from error in criminal justice.
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NIJ developed the
Sentinel Events Initiative Strategic Research and Implementation Plan to describe its current and projected efforts to explore, develop, and evaluate a mechanism for learning from error in criminal justice.
This document will be of interest to researchers (academic, governmental, and industry); federal, state, and local government partners; as well as justice policymakers, practitioners, and communities. It provides a summary of the Sentinel Events Initiative (SEI) and its progress to date, and offers a roadmap for NIJ’s plans for expansion. As with all federal programs, this expansion is dependent on funding availability. Findings from the activities that fall within this strategic research plan will be disseminated among constituents and partners in ways designed to achieve the greatest impact.
What Is a Sentinel Event?
A sentinel event is a significant, unexpected negative outcome that
- Signals possible underlying weaknesses in a system or process.
- Is likely the result of compound errors.
- May provide keys to preventing future adverse events or outcomes.
[Just a placeholder]
A police-citizen encounter that unexpectedly turn violent.
The release from prison of a person who quickly reoffends.
In-custody deaths or injuries including self-harm and suicide in prisons.
The wrongful arrest or conviction of an innocent person.
Violations of an individual’s right to a speedy trial.
Ineffective assistance of counsel or lack of access to sufficient legal assistance. Unreasonable delays in forensic evidence processing.
A sentinel event could also include a “near miss” event, one in which a bad outcome may have occurred but for extraordinary actions of an individual or a last-minute identification of the impending error by an individual or system process.
Currently, the U.S. criminal justice system lacks mechanisms by which to learn from its mistakes and prevent their recurrence. Sentinel event reviews provide such a mechanism by breaking down silos across the system, and shifting the culture from one of retroactive blame to one of forward-looking solutions. SEI aims to enable the creation of a system that acknowledges inherent weaknesses and works collaboratively to effect continual system improvements that minimize preventable harm.
message from NIJ Acting Director Howard Spivak about this strategic research plan.
Though this approach is more focused in action research and program development than NIJ’s traditional portfolios, NIJ is the ideal incubator for this potentially transformative concept. By building a program grounded in science and regular evaluation, NIJ is supporting the development, implementation, and possible adoption of a rigorous approach that not only reveals system weaknesses, but also identifies high-priority areas where further scientific exploration is needed to support system improvements.
Sentinel event reviews aim to unpack the causes of and contributing factors to these incidents in a complex, adversarial system. Used in medical fields for decades in order to learn from error, these reviews are based on three fundamental principles:
Nonblaming: Reviews must not be framed as a hunt for a bad actor. Rather, they must seek to understand why multiple, smaller errors occurred; why decisions seemed like the best decisions at the time; and how the system is structured to allow for such mistakes.
Forward-looking: Reviews must be conducted for the purpose of learning, with an eye toward using information to improve policy and practice, and to reduce the likelihood of future harm.
All-stakeholder: Reviews must include representatives from all aspects of the system whose actions and/or failure to act could have reasonably contributed to the error. They must be willing and able to share all relevant information across disciplines to inform a deliberative, transparent process.
By regularly bringing multiple stakeholders to the table to collaboratively identify root causes of system errors, these reviews are designed to reveal weaknesses in policies and practices, as well as determine how best to correct or mitigate them. Routinizing sentinel event reviews as an ongoing, embedded practice helps ensure continual process improvement and system optimization, leading to increased system reliability and greater public confidence in the system’s legitimacy, while minimizing preventable harm.
Individuals poised to contribute to improving the criminal justice system through these reviews include but are not limited to: law enforcement, corrections, courts, probation, and parole officers; victim advocates; defenders; prosecutors; forensic scientists; and city and risk managers. NIJ also acknowledges that these improvements must reflect the perspective and experiences of victims and their families, exonerees, incarcerated persons and their families, and the community at large.
A Call for Collaboration
The program development and research directions included within this strategic research plan intentionally span many scientific and practitioner disciplines. The breadth of the plan is driven by the magnitude of questions that need to be researched within the criminal justice system in order to minimize preventable harm. NIJ envisions that researching, evaluating, and implementing sentinel event reviews as part of this agenda will require both interdisciplinary collaboration among criminal justice agencies and partnerships between researchers of varying disciplines, practitioners, and communities. Finally, mirroring the need for collaboration, NIJ will seek partnerships with other federal agencies and private institutions that support the development and adoption of sentinel event reviews and other learning-from-error mechanisms. These partnerships may include: fostering support for expanded funding; establishing public-private partnerships to support the implementation and evaluation of sentinel event reviews; co-sponsoring research awards; convening meetings to bring key players together; exploring the establishment of an SEI Center of Excellence to support implementation and evaluation; and nurturing an engaging national discourse on learning from error within the criminal justice system.
Summary of Strategic Priorities
NIJ’s primary focus is on answering three overarching research questions with regard to sentinel events:
- Can nonblaming, all-stakeholder, forward-looking reviews of sentinel events be implemented in the criminal justice context?
- If such reviews are implemented, can they provide jurisdictions with the information necessary to inform procedures and practice, and will this contribute to system improvement?
- If these reviews can be implemented in the criminal justice context, and if these reviews do contribute to system improvements, can these reviews be routinized and sustained over time?
Because these types of reviews exist in such a limited capacity in U.S. criminal justice systems, NIJ must not only design evaluations, but also build the sample of reviews to evaluate. Accordingly, NIJ’s strategic priorities span the breadth of socializing the concept, understanding promising practices for review implementation (and barriers thereto), and implementing and evaluating sentinel event reviews at the local level.
Strategic Priority I: Advance the Concept of Learning From Errors in Criminal Justice
The concept of proactively identifying errors and freely engaging in frank discourse among multiple stakeholders in the criminal justice system is a novel one. NIJ is committed to educating criminal justice stakeholders and community partners on the concept of learning from error, and identifying early adopters and credible messengers to support this process.
Sentinel event reviews were initially developed to better understand the causes of industrial accidents. They were then adapted with considerable success in the medical and transportation industries, particularly in the field of aviation. Former NIJ Visiting Fellow James Doyle first developed the concept of using sentinel event reviews in criminal justice, and through his two-year fellowship built the foundation for programmatic development and evaluation. NIJ has since built the framework for a rigorous exploration and expansion of sentinel event reviews in criminal justice, and hosted an expert convening of practitioners, policymakers, and researchers in May 2013 to advance the concept, as well as to better understand challenges facing implementation and how best to overcome them.
The objectives supporting Strategic Priority I build on NIJ’s prior efforts to socialize the concept of sentinel event reviews with criminal justice stakeholders, and leverages the country’s most recent interest in and commitment to improving and advancing the criminal justice system. NIJ will continue to work with partners, including other federal agencies, to encourage the integration of learning from error in reform and improvement efforts.
Objective I.1: Encourage and inform discourse on criminal justice system improvements through sentinel event reviews.
Objective I.2: Connect with community stakeholders, and begin to link learning-from-error efforts with interests in reconciliation and rebuilding between communities and local criminal justice systems.
Objective I.3: Identify complementary efforts within the criminal justice system to leverage enthusiasm, distinguish the SEI, and ensure fidelity to the concept.
Objective I.4: Forge sustainable partnerships with professional organizations, legislative bodies, and program advocates who can serve as credible messengers of SEI’s promise.
View the action plan for Strategic Priority I.
Strategic Priority II: Understand Contextual Drivers and Barriers, and Identify Promising Practices for Sentinel Event Reviews
Since the inception of SEI, NIJ has made great strides in understanding the potential drivers of and barriers to applying a sentinel events approach in the criminal justice system, but more work is necessary to identify promising practices and to test sentinel event reviews in varying contexts, such as within justice agencies of varying sizes and missions that have with different resource levels.
In 2014, NIJ developed research solicitations to explore how sentinel events can be used to improve the administration of justice and to better understand the contextual challenges the criminal justice system presents. NIJ is currently funding four research projects through this portfolio, with the first round of final results anticipated in 2017. Future research should focus on better understanding the drivers and contextual challenges inherent in implementing and advancing sentinel event reviews in criminal justice.
The objectives supporting Strategic Priority II build on previous NIJ investments in understanding the fundamental elements affecting reviews, increasing the rigorous evidence base supporting these reviews, and integrating research findings from multiple fields to inform a multidisciplinary response.
Objective II.1: Establish a community of practice of multidisciplinary stakeholder partners to ensure program design reflects what the field needs and has the capacity to support.
Objective II.2: Conduct legal and policy reviews across multiple jurisdictions to determine policy and legislative landscape.
Objective II.3: Continue to build an evidence base through research solicitations, with an emphasis on multidisciplinary approaches and innovative methodology. Also assemble literature reviews, white papers, and expert working groups to explore priority issues and identify promising practices.
Objective II.4: Conduct literature reviews and develop white papers on relevant issues and current reflections.
View the action plan for Strategic Priority II.
Strategic Priority III: Explore the Adoption of Evidence-Based Sentinel Event Reviews and Evaluations Thereof
NIJ aims to explore and better understand the adoption of sentinel event reviews on a broad scale, particularly given the complexity and diversity of criminal justice systems at the jurisdictional level.
In 2014, NIJ launched the SEI beta project, in which three pilot jurisdictions successfully conducted a single multi-stakeholder sentinel event review. NIJ has published a number of articles on lessons learned and programmatic development thus far, based on the results of this beta project.
Building on lessons learned from these efforts, NIJ is now poised to explore the expansion of sentinel event reviews in multiple jurisdictions, as a means to further knowledge development and program improvement. NIJ will encourage and support jurisdictions to adopt the core tenets of the sentinel events approach, tailoring each effort to meet local needs and capacity. NIJ will facilitate evaluations of local efforts throughout the process, ensuring that lessons learned and promising practices will shape continued efforts. NIJ’s intent is not to create a “one-size-fits-all” approach to implementation. Rather, NIJ aims to identify a set of promising strategies for conducting sentinel event reviews that can be uniquely tailored to each jurisdiction and subsequently evaluated.
While additional sentinel review pilots must be conducted, institutionalized, and evaluated in order for the true impact of these reviews to be understood, NIJ strongly believes that this promising practice warrants consideration by any jurisdiction seeking to learn from errors, minimize preventable harm, and improve both the efficacy and legitimacy of its criminal justice system.
The objectives supporting Strategic Priority III build on previous efforts to explore the implementation of sentinel event reviews at the jurisdictional level. This objective integrates and leverages analogous efforts, while seeking to specifically advance and understand the impact of sentinel event reviews as a distinct approach to learning from error in criminal justice.
Objective III.1: Identify and brief federal partners who are positioned to advance the sentinel event review concept.
Objective III.2: Generate a work plan and establish a funding mechanism for an entity to oversee the development of pilot sites and support those sites through implementation and evaluation.
Objective III.3: Establish a communication mechanism for interested state and local jurisdictions to explore what a sentinel event review entails, and engage in preliminary discussions about the possibility of implementation.
Objective III.4: Launch pilot demonstration sites across the United States.
Objective III.5: Continuously evaluate demonstration sites, and revise future implementation plans accordingly.
View the action plan for Strategic Priority III.
[note 1]See, e.g., Recommendation 2.3 in
Final Report of the President’s Task Force on 21st Century Policing, Washington, DC: U.S. Department of Justice, Office of Community Oriented Policing Services, May 2015: 22-23; James M. Doyle, “Learning From Error in the Criminal Justice System: Sentinel Event Reviews,” in
Mending Justice: Sentinel Event Reviews, Special Report, Washington, DC: U.S. Department of Justice, National Institute of Justice, September 2014, NCJ 247141: 3-20.
[note 2]The Joint Commission, Sentinel Event Policy and Procedures, October 14, 2016. “The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.”
[note 3]See, e.g., L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds.,
To Err Is Human: Building a Safer Health System (Washington, DC:National Academies Press, 2000).
[note 4] Notes from the expert panel held in Alexandria, Va., in May 2013 were not published. However, many of the panelists contributed articles to
Mending Justice: Sentinel Event Reviews (see fn. 1).
[note 5]See, e.g., Nancy Ritter, “Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice?”
NIJ Journal 276, December 2015,
Mending Justice: Sentinel Event Reviews (see fn. 1),
Paving the Way: Lessons Learned in Sentinel Event Reviews, Washington, DC: U.S. Department of Justice, National Institute of Justice, November 2015, NCJ 249097; James M. Doyle, “NIJ’s Sentinel Events Initiative: Looking Back to Look Forward,”
NIJ Journal 273, November 2013.
Date Created: February 21, 2017