Friday, January 9, 2015

Mending Justice: Sentinel Event Reviews

"How should the criminal justice system respond to errors?

A common response is to seek out 'bad apples,' apportion blame, and conclude that the error has been dealt with once that individual is punished or a policy is changed.

But errors in a complex system are rarely the result of a single act or event. In medicine, aviation and other high-risk enterprises, serious errors are regarded as system errors or 'organizational accidents.' Organizational accidents are potential 'sentinel events,' incidents that could signal more complex flaws that threaten the integrity of the system as a whole. These other complex systems have developed sentinel event reviews — nonblaming, all-stakeholder, forward-leaning mechanisms — to go beyond disciplining rule-breakers in an effort to minimize the risk of similar errors in the future and improve overall system reliability.

Mending Justice: Sentinel Event Reviews explores the potential to learn from errors in the criminal justice system by applying a sentinel event review approach."


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