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Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice?
By Nancy Ritter, NIJ Journal 276
Published: 04/18/2016

The following has been reprinted from NIJ Journal 276

Confidence in our nation’s criminal justice system rests on several core beliefs. First, we believe that most justice work is fairly routine, following a predictable path that makes errors rare. Second, we believe that in the rare instances an error does occur, it is the result of simple negligence or individual misconduct, which “the system” can readily detect and fix. Finally, we believe that processes are in place to ensure that similar errors do not happen again.

The truth, however, is that these beliefs may be largely unfounded. Since 2011, NIJ has been investigating the feasibility of using sentinel event reviews (SERs) in the criminal justice system. Put simply, the theory is that when a bad outcome occurs in a complex social system — like our justice system — it is rarely the result of one person’s mistake. Rather, multiple small errors combine and are exacerbated by underlying weaknesses in the system.

One of the godfathers of this theory of human error and organizational processes is James T. Reason, a renowned British researcher whose work has been used to improve safety in medicine, nuclear power, financial services and aviation. Dr. Reason writes, “We cannot change the human condition, but we can change the conditions in which humans operate.”

Indeed, it is this principle that lies at the core of NIJ’s Sentinel Events Initiative (SEI). The goal of the Initiative is to change the conditions — or culture — in which criminal justice practitioners operate. Just as medicine and aviation have used SERs to instill a “culture of safety,” NIJ’s Initiative explores a routine, culture-changing practice that would lead to greater system reliability and, hence, greater public confidence in the integrity of our criminal justice system.

Sentinel Event Reviews: The Basics

A “sentinel event” is a negative event or outcome that:
  • Signals underlying weaknesses in a system or process.
  • Is likely the result of compound errors.
  • May, if properly understood, provide important keys to strengthening the system and preventing similar adverse outcomes in the future.
In criminal justice, a sentinel event could be the conviction of an innocent person, a police-citizen encounter that unexpectedly turns violent, the release from prison of a dangerous person, or even a “near miss” that could have led to a bad outcome had it not been caught in time. An SER brings together all of the system’s stakeholders (law enforcement, crime laboratory personnel, prosecutors, defense lawyers, judges, corrections officials, victim advocates and others, depending on the event) to review the event and determine — through a deliberative, transparent, nonblaming process — how and why it happened and what can be done to prevent a similar outcome in the future.

From Then to Now

NIJ’s work began with a research question posed by Visiting Fellow James Doyle, a criminal defense lawyer from Boston: Could SERs, which have successfully been institutionalized in fields such as medicine and aviation to improve outcomes, be adopted in the criminal justice system?

In his two-year fellowship at NIJ, Doyle performed what social scientists call “key informant interviews,” talking with criminal justice practitioners and researchers from around the nation. Doyle’s vision — and the positive reactions he received from boots-on-the-ground practitioners, top executives and others throughout the federal, state and local justice systems — helped launch the SEI.

The SEI seeks to answer three empirical questions about using SERs in the justice system:
  1. Can it be done?
  2. Does it help decrease error, increase effectiveness and produce other public safety dividends?
  3. Can it be incorporated into the routine activities of state and local justice processes and sustained over time?
To date, NIJ has reached a number of significant milestones in its work on the SEI. First, NIJ brought together criminal justice experts and potential early adopters to vet the concept. Second, the Institute published Mending Justice: Sentinel Event Reviews (NIJ.gov, keyword: 247141), a special report that discusses Doyle’s two-year “reconnaissance” and includes commentaries from former Attorney General Eric Holder and 16 highly respected criminal justice practitioners and researchers. In 2014, NIJ funded two research projects and followed that up with an NIJ-supported pilot, or beta, project in three jurisdictions to test the first empirical question: Can it be done? And in 2015, NIJ funded two additional research projects to dig deeper into the best ways to bring SERs into the justice system. (See sidebar, “A Glimpse at Ongoing Research Projects.”)

Testing the Concept: The Beta Project

In 2014, NIJ asked jurisdictions from around the country to volunteer to perform an SER. Through a competitive process, it selected three sites: Milwaukee, Philadelphia and Baltimore. NIJ provided minor logistical support, but no funding, to the beta sites.

“It was very rewarding to see the courage and commitment that the beta teams in these three forward-leaning jurisdictions showed,” said Katharine Browning, a social scientist who heads up NIJ’s SEI. “They are true pioneers.”

Each site designed and conducted its own review of an error (a sentinel event) that had occurred in its justice system. Earlier this year, the sites successfully completed their reviews, providing empirical evidence of the feasibility of adopting SERs in the justice system. A summary of the findings from the beta project — Paving the Way: Lessons Learned in Sentinel Event Reviews (NIJ.gov, keyword: 249097) — covers issues such as:
  • How do you choose the right negative event, case or outcome to review?
  • Who should be on the SER team?
  • Who should lead — or serve as the facilitator of — the review?
  • What does “nonblaming” really mean?
  • How do you manage the need to share sensitive data and information with others?
  • How do you measure impact and outcomes?
Katherine Darke Schmitt, a policy advisor to the Assistant Attorney General in the Office of Justice Programs who is working with the NIJ team, visited the three sites and interviewed members of the SER teams. Her assessment revealed three overarching themes when it came to the sites’ choice of a negative event to review: mitigation of legal risk, the age of the event and the need to have broad system participation.

“Perhaps the single most important procedural question facing SERs in the criminal justice system is whether criminal or civil actions regarding the event have been resolved,” Darke Schmitt said. “It doesn’t mean an SER can’t be done if such actions are still pending; it only means that the stakeholders may need to take actions to mitigate any existing or potential legal risks.”

Click here to view the full report.

Nancy Ritter is a writer and editor at NIJ. She is a member of the SEI team.


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