When a significant negative outcome, or "sentinel event," happens in the criminal-justice system, it is rarely the result of a single actor or mistake. Rather, many small misjudgments, oversights and other errors compound to create a context in which a death in custody, a wounded police officer, a failure to provide sufficient probationary supervision or other negative event can occur.
Traditionally, the American criminal-justice system has taken a "bad apple" approach to error that assigns blame after a negative event. Although focusing on individual performance is appropriate in some instances, this approach fails to address the multiple system flaws that may have contributed to a problem. Errors are often caused by many individuals making decisions based on what they see as the best course of action in a given set of circumstances. Often, systems have set up these front-line actors to fail. If we merely punish a single individual without examining larger systemic issues, we miss a crucial opportunity to learn from error and prevent future negative outcomes.
Shifting the criminal-justice culture away from blame and toward safety and improvement is the goal of the National Institute of Justice's Sentinel Events Initiative, which mobilizes a system-oriented approach to error. This is not a "one-size-fits-all-jurisdictions" federal effort. Rather, the Sentinel Events Initiative supports the local development of a review process in which all actors -- law-enforcement officers, prosecutors, judges, victims, advocates and others -- conduct a forward-looking review of a sentinel event to identify and mend contributing system weaknesses.
Rather than simply assigning blame, these reviews ask the question, "How can we keep this from happening again?" Reviews have been implemented to examine the near-miss prosecution of a father wrongly accused, but then cleared, of murder in Illinois; a homicide committed by a minor under supervision in Milwaukee; and wrongful-conviction cases in New York City.
Although it is impossible to put a price tag on justice-system failings, scattered studies give a sense of the magnitude of the cost to taxpayers. Texas, which has paid more than $93 million in compensation, has one of the most generous compensation statutes for wrongfully convicted individuals, allowing a lump-sum payment equal to $80,000 for each year an individual was wrongfully incarcerated as well as monthly annuity payments. Illinois has spent more than $250 million on wrongful convictions, including $156 million for legal settlements. In addressing factors that will eliminate the need for future compensation and lawsuits, sentinel-event reviews can help mitigate these costs, as well as the unquantifiable impact on the lives of the wrongfully convicted, the toll sentinel events can take on officer welfare, and the danger of the real perpetrators walking free.
The Sentinel Events Initiative draws inspiration from medicine and aviation, which have used these reviews to increase safety, lower costs and instill a culture of continuous improvement. As one seminal patient-safety paper put it, these reviews take the approach that "every defect is a treasure."
After years of scientific research, practitioner outreach and pilot efforts, last month the National Institute of Justice launched a $1.6 million national sentinel-event demonstration project in partnership with the Bureau of Justice Assistance. This project will enable state and local sentinel-event review panels across the country to learn how to best empower jurisdictions to explore system weaknesses and generate locally tailored solutions to mitigate risk and improve system-wide performance.
In viewing negative outcomes as opportunities for learning, local policy influencers can shift the focus of the criminal-justice system away from blame and toward safety and system improvement. In doing so, they have a genuine opportunity reduce risk, save taxpayer money, earn public trust and improve the future administration of justice.
The findings and conclusions in this commentary are those of the authors and do not necessarily reflect the official position or policies of the U.S. Department of Justice.
