This U.S. Department of Justice, National Institute of Justice Web page contains the proceedings from the Sentinel Event Initiative.
This U.S. Department of Justice, National Institute of Justice Web page contains the proceedings from the Sentinel Event Initiative held in Alexandria, VA, in May 2013. The Initiative was a roundtable event convened by the National Institute of Justice to bring together experts to discuss the potential applicability of a "sentinel-events" approach to improving criminal justice outcomes. As described in the overview, a sentinel event is a "significant negative outcome that signals underlying weaknesses in the system or process; that likely is the result of compound errors; and that if properly analyzed and addressed, may provide important keys to strengthening the system and preventing future adverse events or outcomes." The opening presentations examined Wrongful Convictions and Other Sentinel Events: Learning from Organizational Accidents in the Criminal Justice System; and Learning From Errors in Medicine. A discussion on the use of the sentinel approach was held following these presentations. The discussion continued and examined confidentiality and the balance between incident liability and risk management, focusing on the ramifications of notions of blame and shame and protecting potentially culpable practitioners. The final session at the roundtable dealt with making the concept of a sentinel event review process into a reality and implementing it in the criminal justice system. Participants were asked to look at the process from the standpoint of a consumer of a system and determine how the process could be implemented by individual agencies. Finally, participants were asked to consider outstanding issues related to the sentinel event approach to process review.
United States of America