How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews

How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews
Duration: 60 Minutes
Module 1Resources
Recorded on: 2019-10-22
Unit 1Slide Deck: How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews
Unit 2Workbook: How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews
Unit 3Recording: How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews

There is much to be learned from our mistakes and failures – and it is this concept that is the foundation of Sentinel Events. Different industries have employed this learning approach of reviewing and analyzing events that did not quite turn out as expected to improve policies and procedures. This approach has been proven to be effective in the area of law enforcement and criminal justice where public trust, safety, and human lives are at stake.

To discuss the Sentinel Events approach and its intricacies are John Holloway and Dr. Mallory O’Brien. John is the Associate Dean and Executive Director of the Quattrone Center at the University of Pennsylvania Law School. He is a national thought leader in the use of Root Cause Analysis in criminal justice and his interest in research helps agencies turn challenges and misses into opportunities for learning and improvement.  Meanwhile, Mallory is an epidemiologist working for more than 2 decades on fatality and other incident reviews. She currently works with the NIJ and BJA on Sentinel Event Reviews.

Together, they unpack the concept as well as the real-world application of Sentinel Event Reviews in this course. Topics they tackled include:

  • What errors are and the types of errors that are encountered in the field of criminal justice and policing.
  • How other industries prevent errors by employing feedback loops and peer reviews.
  • The goal of reviews to analyze the event, identify contributing factors to the error, and come up with improvements to prevent it moving forward.
  • The importance of shifting the focus from blame to quality and safety in instances where an error or failure occurs.
  • The benefits of conducting event reviews, the types of public health/safety reviews being implemented within the public service arena, and the basic elements and structure of the review.
  • The Swiss Cheese Model that underlines the important roles of stakeholders in ensuring that there are no opportunities for errors to be made.
  • The BJA Demonstration Project that implemented a Sentinel Event Review across 15 jurisdictions for a case of their choosing providing technical assistance and process evaluation support needed.
  • Case studies where a Sentinel Event Review was utilized to analyze the factors that led to the errors.
    • A look into the Lex Street Massacre case and the inaccurate incarceration brought about by false confessions, inaccurate eyewitness identification, poor communication, and media pressure.
    • Milwaukee’s Juvenile Justice and Mental Health case that revealed the multiple opportunities for prevention and intervention that was not provided based on the perpetrator’s history.
  • Addressing Minneapolis’ Overdose Deaths problem through a monthly case review that provides critical information to help identify what the jurisdiction must do to address the issue.
  • The working environment that the case review fostered within the team where there is better representation, coordination, and collaboration.
  • Questions from the webinar attendees concerned:
    • Sentinel event reviews that involved probation and corrections.
    • Handling sentinel event reviews separate from actual investigations.
    • Aviation and medicine’s history and experience on sentinel reviews.
    • The benefits of having a neutral facilitator leading sentinel event reviews


Resource Mentioned: Paving the Way: Lessons Learned from Sentinel Event Reviews


Audience Comments:

  • “That at least there are folks out there that appreciate the fact that improvement needs to happen; I did find the 6 areas where errors are identified very interesting; cold cases, evolving science, forensic errors, intentional misconduct, unintended consequences, unsuccessful circumstances (that about covers every area where “humanness” occurs… Thank you.” — Pamela
  • “Basically confirm that some of the policies and procedures in place in our department are on track with several other examples of possibly how we can improve our response to sentinel events.” — JAMES
  • “My team facilitates root cause analysis reviews for our department. This webinar was a good refresh on some of the process pieces we need to keep in mind. Thanks!” — Susan



Additional Resources
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