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