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Sentinel Event Review for Successful Transition and Reentry Together (START) Program in the Eastern District of Wisconsin

NCJ Number
Date Published
April 2024
72 pages

This document provides a systematic review, or Sentinel Event Review, of the Successful Transition and Reentry Together (START) federal reentry program; it describes the START SER team process and results, noting results and implications for future reviews; and provides in-depth information about the implementation of SER for START, a breakdown of START program outcomes analysis, recommendations for practice, and benefits and considerations for future SERs.


In a complex system, like a hospital system or a criminal justice system, an unexpected, negative occurrence or outcome is rarely the result of a single act, event, or slip-up. More likely the bad outcome is a sentinel event — a significant negative outcome that indicates fundamental weaknesses in the system and which is likely the result of multiple factors. A systematic review of the sentinel event can identify system gaps and opportunities that improve the system and reduce the risk of future bad events. For this reason, the fields of aviation, medicine, and the military conduct a Sentinel Event Review (SER) to assess the processes that resulted in the sentinel event. A SER seeks to identify systemic opportunities for improving processes. NIJ has made investments over the years in applying the SER process in the criminal justice field. The implementation of SER in criminal justice has involved the review of negative outcomes along with “near misses” and even successful outcomes to better understand the specific conditions contributing to negative outcomes. This report discusses the application of the SER process to the Successful Transition and Reentry Together (START) program in the Eastern District of Wisconsin, the first SER in the federal criminal justice system. The SER of START reviewed four cases of individuals who participated in the program. The reviews took reentry failure as their sentinel event, although two of the four cases were successes that the SER team defined as “near misses.”