February 5, 2018
Image source: Unsplash
The criminal justice system lacks a mechanism to review its processes, especially around negative events. When a significant negative outcome, or “sentinel event,” happens, it is rarely because of a single actor or mistake. It is because the system has multiple holes in it that don’t allow for elimination of these kinds of events.
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.
The National Institute of Justice has started its Sentinel Events Initiative to mobilize a system-oriented approach to error and outcomes.
The initiative supports local development of review processes in which all parties conduct a forward-looking review of a sentinel event to identify and mitigate or improve system weaknesses.
Texas has paid more than $93 million in wrongful incarceration compensation. Illinois has spent over $250 million. In addressing system weaknesses and improving outcomes, states can look forward to reducing these costs.
The Sentinel Events Initiative draws inspiration from the aviation and healthcare industries which have more mature structures in place for measuring safety and reviewing processes to help ensure positive outcomes.
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