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Sentinel Events Initiative


The Sentinel Events Initiative (SEI) is a joint project of the Bureau of Justice Assistance (BJA) and the National Institute of Justice (NIJ). It seeks to empower local jurisdictions to take an all-stakeholder, non-blaming, forward-looking approach to learning from errors, with the goal of mitigating future risk. SEI assists jurisdictions to build capacity and conduct their own sentinel event reviews to transform bad events into opportunities to address systemic flaws, prevent their recurrence, and earn public trust, thereby increasing safety, lowering costs, and instilling a culture of disclosure.

What is a Sentinel Event?

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.

Apply for Sentinel Event Assistance

The National Demonstration Collaboration is recruiting a broad range of jurisdictions interested in conducting one or more sentinel event reviews. Sites will receive technical assistance to establish a review team, negotiate confidentiality and information-sharing agreements, understand the review principles and theories of change, conduct reviews that draw on promising practices, and generate recommendations for system improvements in their jurisdiction. The goal of this project is to empower sites to design a review process that is tailored to their jurisdiction and can be sustained beyond their engagement with the National Demonstration Collaboration.

Applications are reviewed on a rolling basis. Visit the Demonstration Project page to learn more.


Watch the April 17, 2019, The Sentinel Events Initiative: Becoming a Demonstration Site webinar recording for an overview of the sentinel events approach and answers to questions about SEI:

National Demonstration Project Announcement
BJA and NIJ award $1.6 million to the Quattrone Center for the Fair Administration of Justice to empower local communities to conduct collaborative reviews of justice system failings, with the goal of understanding system causes, mitigating risk, and preventing reoccurrence of negative outcomes at the local level.

All-Stakeholder Forum Report
In June 2017, nearly 100 federal, state, and local criminal justice practitioners, researchers and academics, policymakers, crime survivors, community representatives, and federal partners convened to discuss learning-from-error mechanisms in criminal justice.

Date Created: December 10, 2019