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Sentinel Events Initiative

Sentinel Events

A "sentinel event" is a significant, unexpected, negative outcome that is indicative of wider systemic problems. In criminal justice, a sentinel event might include the premature release from prison of an individual who quickly reoffends or commits a violent crime, the wounding of a police officer by a mentally ill probationer, a wrongful arrest or conviction that leaves the real perpetrator at large, an in-custody death, the loss of probative evidence on a crime scene or in a lab, an out-of-policy police shooting, or a "good catch" in which a negative event was narrowly avoided.

Historically, the American criminal justice system has taken a "bad apple" approach to these errors in which blame is assigned to an individual or agency after a negative event. However, data show that errors and bad outcomes are often caused by the combination of many actors making decisions based on what they see as the best course of action in a given set of circumstances. While focusing on individual performance is appropriate in some instances, this "bad apple" approach fails to address the multiple system causes that may have contributed to a problem. A blame-focused approach assumes that a practitioner intended to make a mistake and could be deterred by fear of punishment, when at the time, the individual often made what they considered the best possible decision, given a set of circumstances. If we only punish single actors without examining these larger systemic issues, we miss a crucial opportunity to learn, develop system improvements, and prevent future bad outcomes.

The Sentinel Events Initiative (SEI) takes a system-oriented approach to negative outcomes and error, with the goal of shifting criminal justice culture toward safety and improvement and away from laying blame on frontline workers. SEI supports a review process in which all individuals whose actions or inactions may have contributed to an event are engaged and empowered to develop solutions to prevent future bad outcomes. Through sentinel event reviews, law enforcement officers, prosecutors, judges, forensic scientists, and others come together to conduct a non-blaming, forward-looking review of a bad outcome and develop recommendations for preventing reoccurrence.

SEI is a joint project of the Bureau of Justice Assistance and the National Institute of Justice. The initiative is not a federal program imposing a premeditated formula on local jurisdictions or agencies. Rather, SEI aims to empower jurisdictions to build capacity and conduct their own reviews, which will mitigate future risk and reduce costs. Medicine, aviation, and other high-risk fields have used reviews to increase safety, lower costs, and instill a culture of disclosure. Drawing inspiration from these fields, sentinel event reviews in criminal justice transform bad events into opportunities for jurisdictions to address systemic flaws, prevent their recurrence, and earn public trust.

Date Created: December 10, 2019